Provider Demographics
NPI:1114219813
Name:AGHEKIAN, ANDRE ALEX (PTA)
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:ALEX
Last Name:AGHEKIAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:VERDUGO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91046-0646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4655 RUFFNER ST
Practice Address - Street 2:STE 207
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2275
Practice Address - Country:US
Practice Address - Phone:800-877-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3834225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant