Provider Demographics
NPI:1053341776
Name:ARDALAN, FOROOZAN (LAC)
Entity type:Individual
Prefix:MRS
First Name:FOROOZAN
Middle Name:
Last Name:ARDALAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7606171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC7606Medicare UPIN