=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285382994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANI AGABALIAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2022
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11301 WILSHIRE BLVD BLDG 304
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90073-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-478-3711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2324 DEL MAR RD
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91020-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 35291
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------