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General NPI Number Information
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NPI Number | 1336693894
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Entity Type | Organization
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Legal Business Name | GLENDALE PRIMARY CARE CENTER INC
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Dates
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Enumeration Date | 08/12/2016
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Last Update Date | 01/23/2017
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Provider Practice Location Address
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Address Line | 1204 S CENTRAL AVE
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City | GLENDALE
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State | CA
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Zip | 91204-2504
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Country | US
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Telephone | 818-551-0001
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Fax | 818-551-0074
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Provider Business Mailing Address
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Address Line | 1204 S CENTRAL AVE
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City | GLENDALE
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State | CA
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Zip | 91204-2504
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Country | US
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Telephone | 818-551-0001
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Fax | 818-551-0074
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MERI ANTOSSYAN
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Credential | DO
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Telephone | 818-551-0001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20A13819
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License Number State | CA
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