MEDICARE: GLENDALE PRIMARY CARE CENTER INC

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	207Q00000X	Family Medicine Physician	20A13819	CA

General Provider Information

NPI Number	:	1336693894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDALE PRIMARY CARE CENTER INC

Provider Business Mailing Address
First Line	:	1204 S CENTRAL AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-2504
Country	:	US
Telephone Number	:	818-551-0001
Fax Number	:	818-551-0074

Provider Business Practice Location Address
First Line	:	1204 S CENTRAL AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-2504
Country	:	US
Telephone Number	:	818-551-0001
Fax Number	:	818-551-0074

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	MERI ANTOSSYAN
Credential	:	DO
Telephone Number	:	818-551-0001

Provider Enumeration Date	:	08/12/2016
Last Update Date	:	01/23/2017

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