Provider Demographics
NPI:1750402574
Name:GENETIC INSTITUTE OF ANTI AGING
Entity type:Organization
Organization Name:GENETIC INSTITUTE OF ANTI AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:SAEED
Authorized Official - Last Name:KHARAZMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-641-2640
Mailing Address - Street 1:720 PAULARINO AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2940
Mailing Address - Country:US
Mailing Address - Phone:714-641-2640
Mailing Address - Fax:714-641-2646
Practice Address - Street 1:720 PAULARINO AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2940
Practice Address - Country:US
Practice Address - Phone:714-641-2640
Practice Address - Fax:714-641-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77981170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty