Provider Demographics
NPI:1992524169
Name:AVETISYAN, TIGRAN
Entity type:Individual
Prefix:
First Name:TIGRAN
Middle Name:
Last Name:AVETISYAN
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 1:1516 E BROADWAY APT 2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1565
Mailing Address - Country:US
Mailing Address - Phone:818-799-8926
Mailing Address - Fax:
Practice Address - Street 1:1516 E BROADWAY APT 2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1565
Practice Address - Country:US
Practice Address - Phone:818-799-8926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95372225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist