Provider Demographics
NPI:1730503749
Name:KHALAJHEDAYATI, FAKHTEH
Entity type:Individual
Prefix:
First Name:FAKHTEH
Middle Name:
Last Name:KHALAJHEDAYATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5911 HEIL AVE STE F
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3752
Mailing Address - Country:US
Mailing Address - Phone:714-377-2257
Mailing Address - Fax:714-377-2256
Practice Address - Street 1:5911 HEIL AVE STE F
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3752
Practice Address - Country:US
Practice Address - Phone:714-377-2257
Practice Address - Fax:714-377-2256
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15477171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist