MEDICARE: MIH PROJECT A, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	550004114	CA

General Provider Information

NPI Number	:	1033697230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIH PROJECT A, LLC

Provider Business Mailing Address
First Line	:	12611 AMBOY AVE
Second Line	:
City	:	SYLMAR
State	:	CA
Zip	:	91342-3606
Country	:	US
Telephone Number	:	818-336-6766
Fax Number	:

Provider Business Practice Location Address
First Line	:	12611 AMBOY AVE
Second Line	:
City	:	SYLMAR
State	:	CA
Zip	:	91342-3606
Country	:	US
Telephone Number	:	818-334-3408
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN GEVORGYAN
Credential	:
Telephone Number	:	818-336-6766

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	02/27/2020

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