Provider Demographics
NPI:1609475706
Name:BARADAR HERISTCHIAN, BOZORGMEHR (DPT)
Entity Type:Individual
Prefix:
First Name:BOZORGMEHR
Middle Name:
Last Name:BARADAR HERISTCHIAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11231 PICKFORD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3120
Mailing Address - Country:US
Mailing Address - Phone:310-780-1893
Mailing Address - Fax:
Practice Address - Street 1:201 N ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1729
Practice Address - Country:US
Practice Address - Phone:404-303-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist