Provider Demographics
NPI:1790965945
Name:GRIGORYAN, GRIGOR
Entity Type:Individual
Prefix:MR
First Name:GRIGOR
Middle Name:
Last Name:GRIGORYAN
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 1:2720 E PALMDALE BLVD
Mailing Address - Street 2:SUITE #124
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4930
Mailing Address - Country:US
Mailing Address - Phone:661-272-0004
Mailing Address - Fax:661-272-0006
Practice Address - Street 1:2720 E PALMDALE BLVD
Practice Address - Street 2:SUITE #124
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4930
Practice Address - Country:US
Practice Address - Phone:661-272-0004
Practice Address - Fax:661-272-0006
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20365332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4987030001OtherMEDICARE ID