Provider Demographics
NPI:1174667679
Name:KHECHUMYAN, STEPAN
Entity Type:Individual
Prefix:
First Name:STEPAN
Middle Name:
Last Name:KHECHUMYAN
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 1:903 E ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4837
Mailing Address - Country:US
Mailing Address - Phone:818-623-0992
Mailing Address - Fax:818-755-0733
Practice Address - Street 1:903 E ACACIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4837
Practice Address - Country:US
Practice Address - Phone:818-623-0992
Practice Address - Fax:818-755-0733
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01040F343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01040FMedicaid