Provider Demographics
NPI:1619055670
Name:MOJABE, MOHAMMAD REZA (DC)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:REZA
Last Name:MOJABE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3576
Mailing Address - Country:US
Mailing Address - Phone:909-466-7363
Mailing Address - Fax:909-466-7365
Practice Address - Street 1:9555 FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3576
Practice Address - Country:US
Practice Address - Phone:909-466-7363
Practice Address - Fax:909-466-7365
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 21064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0210640Medicare ID - Type Unspecified