Healthcare Provider Details

I. General information

NPI: 1104451921
Provider Name (Legal Business Name): MARINE KUPALYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE 22-387 MDCC
LOS ANGELES CA
90095-1752
US

IV. Provider business mailing address

10833 LE CONTE 22-387 MDCC
LOS ANGELES CA
90095-1752
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5930
  • Fax: 310-794-7338
Mailing address:
  • Phone: 310-825-5930
  • Fax: 310-794-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95145365
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: