Provider Demographics
NPI:1578055364
Name:PEDRAM, NOGOL
Entity Type:Individual
Prefix:
First Name:NOGOL
Middle Name:
Last Name:PEDRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 S SPRING ST #13308
Mailing Address - Street 2:SMB 7649
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013
Mailing Address - Country:US
Mailing Address - Phone:559-326-8395
Mailing Address - Fax:
Practice Address - Street 1:860 HAMPSHIRE RD STE P
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-6020
Practice Address - Country:US
Practice Address - Phone:805-852-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
261QM1300X, 261QP2000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy