1114077328 NPI number — AVETIS AVETISYAN

Table of content: (NPI 1114077328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114077328 NPI number — AVETIS AVETISYAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVETIS AVETISYAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
A&T MEDICAL SUPPLY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114077328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1133 EL CAMINO REAL
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
SOUTH SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94080-3288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-872-7002
Provider Business Mailing Address Fax Number:
650-872-0441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1133 EL CAMINO REAL STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94080-3288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-872-7002
Provider Business Practice Location Address Fax Number:
650-872-0441
Provider Enumeration Date:
01/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AVETISYAN
Authorized Official First Name:
AVETIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
650-872-7002

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  102525 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 620-18-6957 . This is a "OWNERS SS #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: B6972866 . This is a "OWNERS DRIVER LINCES #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DME03047F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".