Provider Demographics
NPI:1720224785
Name:RAEISGHASEM, AMENEH (DC)
Entity Type:Individual
Prefix:DR
First Name:AMENEH
Middle Name:
Last Name:RAEISGHASEM
Suffix:
Gender:F
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:PO BOX 1435
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-0143
Mailing Address - Country:US
Mailing Address - Phone:617-899-8217
Mailing Address - Fax:
Practice Address - Street 1:3800 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5354
Practice Address - Country:US
Practice Address - Phone:617-899-8217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2579111N00000X
CA31515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor