Provider Demographics
NPI:1205921640
Name:TALLE, MEHRZAD (LAC)
Entity type:Individual
Prefix:
First Name:MEHRZAD
Middle Name:
Last Name:TALLE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TEPOLITO
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1503
Mailing Address - Country:US
Mailing Address - Phone:949-709-2912
Mailing Address - Fax:
Practice Address - Street 1:1804 N. PLACENTIA AVE
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-2303
Practice Address - Country:US
Practice Address - Phone:714-528-9400
Practice Address - Fax:714-528-9403
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4386171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist