Healthcare Provider Details

I. General information

NPI: 1073781886
Provider Name (Legal Business Name): BEN DJABOURIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: VITO'S PEDORTHIC CENTER

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 E. ROWLAND ST. SUITE 2
COVINA CA
91723-3000
US

IV. Provider business mailing address

153 E ROWLAND ST
COVINA CA
91723-3049
US

V. Phone/Fax

Practice location:
  • Phone: 626-858-9460
  • Fax: 626-858-9767
Mailing address:
  • Phone: 626-858-9460
  • Fax: 626-858-9767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0306
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: