Healthcare Provider Details

I. General information

NPI: 1720761471
Provider Name (Legal Business Name): JOHN HOVANES GRALYAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 106
GRESHAM OR
97030-3381
US

IV. Provider business mailing address

7135 COLDWATER CANYON AVE APT 11
NORTH HOLLYWOOD CA
91605-4937
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1123
  • Fax:
Mailing address:
  • Phone: 818-624-1932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304211
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: