Provider Demographics
NPI:1255361952
Name:ARDALAN CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:ARDALAN CHIROPRACTIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ARDALAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:818-995-4488
Mailing Address - Street 1:17200 VENTURA BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4005
Mailing Address - Country:US
Mailing Address - Phone:818-995-4488
Mailing Address - Fax:818-995-3140
Practice Address - Street 1:17200 VENTURA BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4005
Practice Address - Country:US
Practice Address - Phone:818-995-4488
Practice Address - Fax:818-995-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23493111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18928Medicare ID - Type Unspecified
CAU57515Medicare UPIN