Provider Demographics
NPI:1194545467
Name:HOVHANNISYAN, SUREN
Entity type:Individual
Prefix:
First Name:SUREN
Middle Name:
Last Name:HOVHANNISYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18702 NATHAN HILL DR
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-3447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18702 NATHAN HILL DR
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91351-3447
Practice Address - Country:US
Practice Address - Phone:818-482-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty