Provider Demographics
NPI:1194093393
Name:GRIGORYAN, ANAHIT ANA
Entity type:Individual
Prefix:
First Name:ANAHIT
Middle Name:ANA
Last Name:GRIGORYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4448 EAGLE ROCK BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-3512
Mailing Address - Country:US
Mailing Address - Phone:323-257-5535
Mailing Address - Fax:323-257-5396
Practice Address - Street 1:4448 EAGLE ROCK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-3512
Practice Address - Country:US
Practice Address - Phone:323-257-5535
Practice Address - Fax:323-257-5396
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101183332B00000X
CA18131332B00000X
CAC17386335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02836FMedicaid
CA4139790001Medicare PIN