Provider Demographics
NPI:1336693894
Name:GLENDALE PRIMARY CARE CENTER INC
Entity type:Organization
Organization Name:GLENDALE PRIMARY CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOSSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-551-0001
Mailing Address - Street 1:1204 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2504
Mailing Address - Country:US
Mailing Address - Phone:818-551-0001
Mailing Address - Fax:818-551-0074
Practice Address - Street 1:1204 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2504
Practice Address - Country:US
Practice Address - Phone:818-551-0001
Practice Address - Fax:818-551-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB262587Medicare PIN