Provider Demographics
NPI:1366952152
Name:ESMAILZADEH K, SHABNAM (LAC)
Entity type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:ESMAILZADEH K
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:PO BOX 7663
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-7663
Mailing Address - Country:US
Mailing Address - Phone:949-500-1694
Mailing Address - Fax:
Practice Address - Street 1:31872 COAST HWY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-6773
Practice Address - Country:US
Practice Address - Phone:949-499-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist