Healthcare Provider Details

I. General information

NPI: 1811947906
Provider Name (Legal Business Name): AVETIS KHACHIKIAN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S CHEVY CHASE DR #105
GLENDALE CA
91205-4431
US

IV. Provider business mailing address

801 S CHEVY CHASE DR
GLENDALE CA
91205-4432
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-5299
  • Fax: 818-637-7607
Mailing address:
  • Phone: 818-242-5299
  • Fax: 818-637-7607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: