Healthcare Provider Details

I. General information

NPI: 1699303628
Provider Name (Legal Business Name): TRI-STATE COMMUNITY HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4137 VERDUGO RD
LOS ANGELES CA
90065-3820
US

IV. Provider business mailing address

4141 1/2 VERDUGO RD
LOS ANGELES CA
90065-3820
US

V. Phone/Fax

Practice location:
  • Phone: 323-344-9255
  • Fax: 323-344-8776
Mailing address:
  • Phone: 323-297-0884
  • Fax: 323-274-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ARAM MANOUKIAN
Title or Position: CEO
Credential:
Phone: 323-297-0884