1932695079 NPI number — MISSAK KLTCHIAN MD INC.

Table of content: (NPI 1932695079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932695079 NPI number — MISSAK KLTCHIAN MD INC.

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
MISSAK KLTCHIAN MD INC.
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:
Provider Other Organization Name Type Code:
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:
1932695079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4645 HOLLYWOOD BLVD STE 2/4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90027-5455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-661-4500
Provider Business Mailing Address Fax Number:
323-661-3260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4645 HOLLYWOOD BLVD STE 2/4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90027-5455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-661-4500
Provider Business Practice Location Address Fax Number:
323-661-3260
Provider Enumeration Date:
07/02/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KLTCHIAN
Authorized Official First Name:
MISSAK
Authorized Official Middle Name:
Authorized Official Title or Position:
MD / PRESIDENT
Authorized Official Telephone Number:
323-661-4500

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A52368 , 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: 00A52368 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255359840 . This is a "MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1578901237 . This is a "MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".