Healthcare Provider Details

I. General information

NPI: 1366582629
Provider Name (Legal Business Name): VACHAGAN AKOPYAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S HENNEPIN AVE # 195
DIXON IL
61021-3083
US

IV. Provider business mailing address

14417 CHASE ST # 206
PANORAMA CITY CA
91402-3017
US

V. Phone/Fax

Practice location:
  • Phone: 815-713-6589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateIL

VIII. Authorized Official

Name: VACHAGAN AKOPYAN
Title or Position: PRESIDENT
Credential:
Phone: 815-713-6589