Healthcare Provider Details

I. General information

NPI: 1225120587
Provider Name (Legal Business Name): PAVEL GRYUNSHPAN CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S FAIRFAX AVE # 201
LOS ANGELES CA
90036-3148
US

IV. Provider business mailing address

425 S FAIRFAX AVE # 201
LOS ANGELES CA
90036-3148
US

V. Phone/Fax

Practice location:
  • Phone: 323-936-0149
  • Fax: 323-936-0173
Mailing address:
  • Phone: 323-936-0149
  • Fax: 323-936-0173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License NumberDC29542
License Number StateCA

VIII. Authorized Official

Name: DR. PAVEL GRYUNSHPAN
Title or Position: OWNER
Credential: D.C.
Phone: 323-936-0149