Provider Demographics
NPI:1336380872
Name:KHODABANDELOO, ELHAM (LAC)
Entity type:Individual
Prefix:MS
First Name:ELHAM
Middle Name:
Last Name:KHODABANDELOO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1633 PEREIRA DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6830
Mailing Address - Country:US
Mailing Address - Phone:650-269-9425
Mailing Address - Fax:650-488-7117
Practice Address - Street 1:1411 MARSH ST STE 106
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2967
Practice Address - Country:US
Practice Address - Phone:805-439-1581
Practice Address - Fax:650-488-7117
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12645171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist