Provider Demographics
NPI:1457637027
Name:BOUKIDJIAN, BERTHE (RD)
Entity Type:Individual
Prefix:MRS
First Name:BERTHE
Middle Name:
Last Name:BOUKIDJIAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20230 KESWICK ST UNIT 19
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-4463
Mailing Address - Country:US
Mailing Address - Phone:818-450-7441
Mailing Address - Fax:
Practice Address - Street 1:18372 CLARK ST STE 228
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3555
Practice Address - Country:US
Practice Address - Phone:818-881-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1074313133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered