Provider Demographics
NPI:1659796258
Name:BOOLGHOORJIAN, SHANT
Entity Type:Individual
Prefix:
First Name:SHANT
Middle Name:
Last Name:BOOLGHOORJIAN
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 1:5727 HILLVIEW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5727 HILLVIEW PARK AVENUE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-481-2941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health