Healthcare Provider Details

I. General information

NPI: 1902209992
Provider Name (Legal Business Name): PACIFIC HEALTH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S BRAND BLVD
GLENDALE CA
91204-1701
US

IV. Provider business mailing address

319 S BRAND BLVD
GLENDALE CA
91204-1701
US

V. Phone/Fax

Practice location:
  • Phone: 818-240-0006
  • Fax: 818-240-0038
Mailing address:
  • Phone: 818-240-0006
  • Fax: 818-240-0038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberA113904
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberA113904
License Number StateCA

VIII. Authorized Official

Name: DR. GAYANE BEGOYAN
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 818-240-0006