Provider Demographics
NPI:1972258382
Name:KHODAGHOLIAN, SERLI
Entity Type:Individual
Prefix:
First Name:SERLI
Middle Name:
Last Name:KHODAGHOLIAN
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 1:13615 VICTORY BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1775
Mailing Address - Country:US
Mailing Address - Phone:818-994-4724
Mailing Address - Fax:866-384-0262
Practice Address - Street 1:13615 VICTORY BLVD STE 116
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1775
Practice Address - Country:US
Practice Address - Phone:818-994-4724
Practice Address - Fax:866-384-0262
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)