=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194733204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARA PODIATRISTS' GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 05/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1257 W. SAN BERNARDINO RD
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91722-0980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-331-7391
-----------------------------------------------------
Fax | 626-339-0613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1980
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91722-0980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-331-7391
-----------------------------------------------------
Fax | 626-339-0613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HRATCH DEMIRJIAN
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 626-331-7391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | E3993
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------