Provider Demographics
NPI:1821527037
Name:TAVOUKJIAN, NICHOLAS MARK (ATC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:MARK
Last Name:TAVOUKJIAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 E BELLBROOK ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2347
Mailing Address - Country:US
Mailing Address - Phone:626-252-9296
Mailing Address - Fax:
Practice Address - Street 1:200 E DEL MAR BLVD STE 302
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2552
Practice Address - Country:US
Practice Address - Phone:626-683-8536
Practice Address - Fax:626-683-8236
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer