Provider Demographics
NPI:1922421940
Name:GRIGORYAN, EDUARD (LAC)
Entity Type:Individual
Prefix:
First Name:EDUARD
Middle Name:
Last Name:GRIGORYAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E ELMWOOD AVE APT L
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23504 CALABASAS RD
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-4028
Practice Address - Country:US
Practice Address - Phone:424-272-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15704171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist