Provider Demographics
NPI:1851808075
Name:EBRAHIMI, HENGAMEH (LAC)
Entity Type:Individual
Prefix:
First Name:HENGAMEH
Middle Name:
Last Name:EBRAHIMI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30025 ALICIA PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2090
Mailing Address - Country:US
Mailing Address - Phone:818-324-6289
Mailing Address - Fax:
Practice Address - Street 1:29571 MICHELIS ST
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-1686
Practice Address - Country:US
Practice Address - Phone:818-324-6289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16799171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist