Healthcare Provider Details

I. General information

NPI: 1821527037
Provider Name (Legal Business Name): NICHOLAS MARK TAVOUKJIAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD STE 302
PASADENA CA
91105-2552
US

IV. Provider business mailing address

2135 E BELLBROOK ST
COVINA CA
91724-2347
US

V. Phone/Fax

Practice location:
  • Phone: 626-683-8536
  • Fax: 626-683-8236
Mailing address:
  • Phone: 626-252-9296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: