Healthcare Provider Details

I. General information

NPI: 1598319691
Provider Name (Legal Business Name): ELBA ALBERTOVNA KHACHATRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date: 03/02/2020
Reactivation Date: 07/19/2022

III. Provider practice location address

1227 CAMPBELL ST
GLENDALE CA
91207-1445
US

IV. Provider business mailing address

1227 CAMPBELL ST
GLENDALE CA
91207-1445
US

V. Phone/Fax

Practice location:
  • Phone: 747-228-4111
  • Fax: 747-444-4031
Mailing address:
  • Phone: 747-228-4111
  • Fax: 747-444-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: