Provider Demographics
NPI:1902055395
Name:BANOONI, AZITA (DC)
Entity Type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:BANOONI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16548 PARK LANE CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-1145
Mailing Address - Country:US
Mailing Address - Phone:323-549-0822
Mailing Address - Fax:
Practice Address - Street 1:16548 PARK LANE CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-1145
Practice Address - Country:US
Practice Address - Phone:323-549-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22280OtherSTATE LICENSE NUMBER