Provider Demographics
NPI:1447974449
Name:KHACHATRYAN, EDGAR ALBERTOVICH
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:ALBERTOVICH
Last Name:KHACHATRYAN
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 1:1227 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-1445
Mailing Address - Country:US
Mailing Address - Phone:747-228-4111
Mailing Address - Fax:
Practice Address - Street 1:1227 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207-1445
Practice Address - Country:US
Practice Address - Phone:747-228-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness