Healthcare Provider Details

I. General information

NPI: 1801851043
Provider Name (Legal Business Name): FAMILY PRACTICE OF GLENDALE A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S CHEVY CHASE DR STE 230
GLENDALE CA
91205-4436
US

IV. Provider business mailing address

1125 E BROADWAY BOX 71
GLENDALE CA
91205-1315
US

V. Phone/Fax

Practice location:
  • Phone: 818-500-5586
  • Fax: 818-500-5587
Mailing address:
  • Phone: 818-500-5586
  • Fax: 818-500-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SIRVARD KHANOYAN
Title or Position: PROGRAM DIRECTOR/ OFFICER/A.O.
Credential: MD
Phone: 818-445-7143