Healthcare Provider Details

I. General information

NPI: 1609413665
Provider Name (Legal Business Name): MR. YAN ZLATIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21001 SHERMAN WAY # 14A
CANOGA PARK CA
91303-1760
US

IV. Provider business mailing address

15270 SUTTON ST APT 206
SHERMAN OAKS CA
91403-3931
US

V. Phone/Fax

Practice location:
  • Phone: 747-230-0424
  • Fax: 818-276-0009
Mailing address:
  • Phone: 818-324-7193
  • Fax: 818-276-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberSLD1035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: