Provider Demographics
NPI:1316332273
Name:HEIDARI, ALI
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:HEIDARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 W HALLANDALE BEACH BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-4344
Mailing Address - Country:US
Mailing Address - Phone:405-921-9669
Mailing Address - Fax:
Practice Address - Street 1:4520 W HALLANDALE BEACH BLVD STE 8
Practice Address - Street 2:
Practice Address - City:PEMBROKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-4344
Practice Address - Country:US
Practice Address - Phone:405-921-9669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12862111N00000X
FLCH14796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor