Provider Demographics
NPI:1164099040
Name:POGOSYAN, MARINE
Entity Type:Individual
Prefix:MRS
First Name:MARINE
Middle Name:
Last Name:POGOSYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 ROCK GLEN AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4321
Mailing Address - Country:US
Mailing Address - Phone:213-700-8228
Mailing Address - Fax:
Practice Address - Street 1:1527 ROCK GLEN AVE APT 101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4321
Practice Address - Country:US
Practice Address - Phone:213-700-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2279P4000X
CA343900000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No2279P4000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPatient Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA343900000XOtherNON EMERGENCY TRANSPORT
CA32-0651700Medicaid