Provider Demographics
NPI:1801266499
Name:LT PROACTIVE CARE CLINIC CALIFORNIA, PA
Entity type:Organization
Organization Name:LT PROACTIVE CARE CLINIC CALIFORNIA, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMBIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:FARBAKHSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-541-7157
Mailing Address - Street 1:1435 EAST ROSEVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-472-2057
Mailing Address - Fax:916-472-2058
Practice Address - Street 1:1435 EAST ROSEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-472-2057
Practice Address - Fax:916-472-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service