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General NPI Number Information
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NPI Number | 1417445487
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Entity Type | Organization
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Legal Business Name | CORE GERIATRIC MEDICAL GROUP LLC
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Dates
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Enumeration Date | 04/25/2018
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Last Update Date | 04/25/2018
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Provider Practice Location Address
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Address Line | 1505 S GLENDALE AVE
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City | GLENDALE
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State | CA
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Zip | 91205-3315
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Country | US
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Telephone | 818-758-9588
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Fax | 818-975-5217
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Provider Business Mailing Address
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Address Line | 1505 S GLENDALE AVE
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City | GLENDALE
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State | CA
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Zip | 91205-3315
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Country | US
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Telephone | 818-758-9588
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Fax | 818-975-5217
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTINE AYVAZYAN
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Credential | MSPA-C
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Telephone | 818-723-8804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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