Provider Demographics
NPI:1760824262
Name:AMIRMOAZZAMI, SAM (DC)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:AMIRMOAZZAMI
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 1:18437 SATICOY ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2911
Mailing Address - Country:US
Mailing Address - Phone:818-343-8700
Mailing Address - Fax:818-343-8703
Practice Address - Street 1:18437 SATICOY ST
Practice Address - Street 2:SUITE 5
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-2911
Practice Address - Country:US
Practice Address - Phone:818-343-8700
Practice Address - Fax:818-343-8703
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28300111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation