1033752811 NPI number — GRIGOR KOSOYAN

Table of content: JACQUELYNN RENEE SCOTT CADC-R (NPI 1407501067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033752811 NPI number — GRIGOR KOSOYAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSOYAN
Provider First Name:
GRIGOR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1033752811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
343 PIONEER DR UNIT 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91203-2738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-709-7774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16301 NORDHOFF ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91343-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-709-7774
Provider Business Practice Location Address Fax Number:
818-810-6919
Provider Enumeration Date:
10/23/2019

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: 310400000X , with the licence number:  197609731 , 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)