Healthcare Provider Details

I. General information

NPI: 1194545467
Provider Name (Legal Business Name): SUREN HOVHANNISYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18702 NATHAN HILL DR
CANYON COUNTRY CA
91351-3447
US

IV. Provider business mailing address

18702 NATHAN HILL DR
CANYON COUNTRY CA
91351-3447
US

V. Phone/Fax

Practice location:
  • Phone: 818-482-0034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: