Provider Demographics
NPI:1033752811
Name:KOSOYAN, GRIGOR
Entity Type:Individual
Prefix:
First Name:GRIGOR
Middle Name:
Last Name:KOSOYAN
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 1:343 PIONEER DR UNIT 105
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2738
Mailing Address - Country:US
Mailing Address - Phone:213-709-7774
Mailing Address - Fax:
Practice Address - Street 1:16301 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-3807
Practice Address - Country:US
Practice Address - Phone:213-709-7774
Practice Address - Fax:818-810-6919
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197609731310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility