Healthcare Provider Details

I. General information

NPI: 1932788510
Provider Name (Legal Business Name): KRISTINEH MELIK-KASUMYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 E COLORADO BLVD # 150
PASADENA CA
91107-3747
US

IV. Provider business mailing address

501 E MAGNOLIA BLVD APT 106
BURBANK CA
91501-1956
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-4168
  • Fax:
Mailing address:
  • Phone: 818-689-6590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: