Healthcare Provider Details

I. General information

NPI: 1417633645
Provider Name (Legal Business Name): KEVORK KEURJIKIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4795 VINELAND AVE STE B
NORTH HOLLYWOOD CA
91602-3546
US

IV. Provider business mailing address

1515 N KINGSLEY DR APT 2
LOS ANGELES CA
90027-5094
US

V. Phone/Fax

Practice location:
  • Phone: 818-639-3402
  • Fax: 818-639-3425
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT303403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: