Provider Demographics
NPI:1942361753
Name:JAFAR MOTTAGHIAN MONAZZAM
Entity Type:Organization
Organization Name:JAFAR MOTTAGHIAN MONAZZAM
Other - Org Name:SOUTH GATE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAFAR
Authorized Official - Middle Name:MOTTAGHIAN
Authorized Official - Last Name:MONAZZAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:323-563-1160
Mailing Address - Street 1:4067 TWEEDY BL
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6146
Mailing Address - Country:US
Mailing Address - Phone:323-563-1160
Mailing Address - Fax:323-563-1169
Practice Address - Street 1:4067 TWEEDY BL
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6146
Practice Address - Country:US
Practice Address - Phone:323-563-1160
Practice Address - Fax:323-563-1169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056719Medicare ID - Type Unspecified