Provider Demographics
NPI:1588911150
Name:POURDAVOOD, MARJAN RAZI (DC, QME)
Entity type:Individual
Prefix:
First Name:MARJAN
Middle Name:RAZI
Last Name:POURDAVOOD
Suffix:
Gender:F
Credentials:DC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 NORTH CENTRAL AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-244-6792
Mailing Address - Fax:818-244-7477
Practice Address - Street 1:610 NORTH CENTRAL AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-244-6792
Practice Address - Fax:818-244-7477
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 25093111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic