Provider Demographics
NPI:1891917142
Name:MOINI, SONBOL TAHEREH (LAC MTOM)
Entity Type:Individual
Prefix:
First Name:SONBOL
Middle Name:TAHEREH
Last Name:MOINI
Suffix:
Gender:F
Credentials:LAC MTOM
Other - Prefix:
Other - First Name:SONBOL
Other - Middle Name:TAHEREH
Other - Last Name:ABEDIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC MTOM
Mailing Address - Street 1:1821 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-315-3090
Mailing Address - Fax:310-453-8056
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:SUITE 610
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-315-3090
Practice Address - Fax:310-453-8056
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4505171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0045050OtherMEDICAL