Provider Demographics
NPI:1760133250
Name:KHAMZIN, AZAT (CMT)
Entity Type:Individual
Prefix:
First Name:AZAT
Middle Name:
Last Name:KHAMZIN
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 INTERCEPTOR ST APT 204B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4720
Mailing Address - Country:US
Mailing Address - Phone:312-383-0480
Mailing Address - Fax:
Practice Address - Street 1:5875 INTERCEPTOR ST APT 204B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4720
Practice Address - Country:US
Practice Address - Phone:312-383-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89035225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist