Provider Demographics
NPI:1295245587
Name:RASTA, TARA (DC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:RASTA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:TARANEH
Other - Middle Name:
Other - Last Name:RASTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22672 LAMBERT ST SUITE 620
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630
Mailing Address - Country:US
Mailing Address - Phone:949-859-5192
Mailing Address - Fax:949-583-2961
Practice Address - Street 1:22672 LAMBERT ST SUITE 620
Practice Address - Street 2:OLSEN CHIROPRACTIC
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630
Practice Address - Country:US
Practice Address - Phone:949-859-5192
Practice Address - Fax:949-583-2961
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33934111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor