Provider Demographics
NPI:1649323064
Name:ROZANNA AVETYAN
Entity type:Organization
Organization Name:ROZANNA AVETYAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROZANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:AVETYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-354-2569
Mailing Address - Street 1:1015 N LAKE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-4575
Mailing Address - Country:US
Mailing Address - Phone:626-398-1250
Mailing Address - Fax:
Practice Address - Street 1:1015 N LAKE AVE STE 202
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-4575
Practice Address - Country:US
Practice Address - Phone:626-398-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08350FMedicaid
CAHHA08350FMedicaid