Provider Demographics
NPI:1073781886
Name:DJABOURIAN, BEN
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:DJABOURIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:VITO'S
Other - Middle Name:PEDORTHIC
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:143 E. ROWLAND ST. SUITE 2
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3000
Mailing Address - Country:US
Mailing Address - Phone:626-858-9460
Mailing Address - Fax:626-858-9767
Practice Address - Street 1:143 E. ROWLAND ST. SUITE 2
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3000
Practice Address - Country:US
Practice Address - Phone:626-858-9460
Practice Address - Fax:626-858-9767
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0306332B00000X
224L00000X, 225000000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4974734OtherMEDICAID PIN
CADME03036FMedicaid
CADME03036FMedicaid