Provider Demographics
NPI:1598319691
Name:KHACHATRYAN, ELBA ALBERTOVNA
Entity Type:Individual
Prefix:
First Name:ELBA
Middle Name:ALBERTOVNA
Last Name:KHACHATRYAN
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 1:1227 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-1445
Mailing Address - Country:US
Mailing Address - Phone:747-228-4111
Mailing Address - Fax:
Practice Address - Street 1:8201 VANTAGE AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-1442
Practice Address - Country:US
Practice Address - Phone:818-389-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2022-12-06
Deactivation Date:2020-03-02
Deactivation Code:
Reactivation Date:2022-07-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility