Healthcare Provider Details

I. General information

NPI: 1538025085
Provider Name (Legal Business Name): ATHENACARE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3857 FOOTHILL BLVD STE 1C
GLENDALE CA
91214-1653
US

IV. Provider business mailing address

3857 FOOTHILL BLVD STE 1C
GLENDALE CA
91214-1653
US

V. Phone/Fax

Practice location:
  • Phone: 818-858-3087
  • Fax:
Mailing address:
  • Phone: 818-858-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMARA PETROSYAN
Title or Position: CEO
Credential:
Phone: 818-858-3087