Provider Demographics
NPI:1043551864
Name:KODZHOGLYAN, GRIGOR
Entity Type:Individual
Prefix:
First Name:GRIGOR
Middle Name:
Last Name:KODZHOGLYAN
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 1:635 W COLORADO BLVD
Mailing Address - Street 2:119
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2089
Mailing Address - Country:US
Mailing Address - Phone:818-551-1800
Mailing Address - Fax:818-551-1802
Practice Address - Street 1:635 W COLORADO ST
Practice Address - Street 2:119
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1175
Practice Address - Country:US
Practice Address - Phone:818-551-1800
Practice Address - Fax:818-551-1802
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)