Healthcare Provider Details

I. General information

NPI: 1568171940
Provider Name (Legal Business Name): AVETIS GEORG GEVORKYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S SAN PEDRO ST
LOS ANGELES CA
90014-2431
US

IV. Provider business mailing address

500 S SAN PEDRO ST
LOS ANGELES CA
90013-2102
US

V. Phone/Fax

Practice location:
  • Phone: 323-303-2835
  • Fax:
Mailing address:
  • Phone: 323-303-2835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: