Provider Demographics
NPI:1760515407
Name:GOLCHEHREH, IRA J (LAC OMD QME)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:J
Last Name:GOLCHEHREH
Suffix:
Gender:M
Credentials:LAC OMD QME
Other - Prefix:
Other - First Name:IRAJ
Other - Middle Name:
Other - Last Name:GOLCHEHREH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC OMD QME
Mailing Address - Street 1:2175D E FRANCISCO BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-485-4411
Mailing Address - Fax:
Practice Address - Street 1:2175D E FRANCISCO BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-485-4411
Practice Address - Fax:415-485-0857
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC003592171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC003592OtherACUPUNCTURE BOARD OF CA