Provider Demographics
NPI:1962778480
Name:MOHEBAN, PARVANEH (CLS)
Entity type:Individual
Prefix:
First Name:PARVANEH
Middle Name:
Last Name:MOHEBAN
Suffix:
Gender:F
Credentials:CLS
Other - Prefix:MS
Other - First Name:PARVANEH
Other - Middle Name:
Other - Last Name:MOHEBAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CLS
Mailing Address - Street 1:1407 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2416
Mailing Address - Country:US
Mailing Address - Phone:818-547-9870
Mailing Address - Fax:818-547-9870
Practice Address - Street 1:5635 CAHUENGA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-2104
Practice Address - Country:US
Practice Address - Phone:818-308-7450
Practice Address - Fax:818-308-7795
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTA44130291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTA 44130OtherCLS
CA24OtherCLS