Healthcare Provider Details

I. General information

NPI: 1952182180
Provider Name (Legal Business Name): KYLE MINASSIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 3582
GLENDALE CA
91221-3582
US

IV. Provider business mailing address

1020 ALLEN AVE
GLENDALE CA
91201-3469
US

V. Phone/Fax

Practice location:
  • Phone: 323-818-7018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: