Provider Demographics
NPI:1598315244
Name:KHATIBLOU, KHODAYAR
Entity Type:Individual
Prefix:DR
First Name:KHODAYAR
Middle Name:
Last Name:KHATIBLOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 BRISTOL ST STE J103
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7918
Mailing Address - Country:US
Mailing Address - Phone:949-742-2087
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE J103
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7918
Practice Address - Country:US
Practice Address - Phone:949-742-2087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor