1063564094 NPI number — STEVEN H KHANJIAN L.P.C., & L.C.A.D.C

Table of content: STEVEN H KHANJIAN L.P.C., & L.C.A.D.C (NPI 1063564094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063564094 NPI number — STEVEN H KHANJIAN L.P.C., & L.C.A.D.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHANJIAN
Provider First Name:
STEVEN
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.P.C., & L.C.A.D.C
Provider Gender Code:
M

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:
1063564094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 TENAFLY RD UNIT 441
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TENAFLY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07670-7020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-857-5909
Provider Business Mailing Address Fax Number:
201-632-6454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1172 E RIDGEWOOD AVE STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07450-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-857-5909
Provider Business Practice Location Address Fax Number:
201-632-6454
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  37LC00126800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 37PC00197500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37LC00126800 . This is a "L.C.A.D.C." identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 37PC00197500 . This is a "L.P.C." identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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