Provider Demographics
NPI:1841689353
Name:RASTEGARPOUR, ERENIA (LVN)
Entity type:Individual
Prefix:
First Name:ERENIA
Middle Name:
Last Name:RASTEGARPOUR
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:ERENIA
Other - Middle Name:DE LOS ANGELES
Other - Last Name:MENDEZ LARIOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:5360 MARENGO AVE APT 75
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2128
Mailing Address - Country:US
Mailing Address - Phone:619-779-6371
Mailing Address - Fax:
Practice Address - Street 1:5696 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1929
Practice Address - Country:US
Practice Address - Phone:619-460-7871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259206164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse