Provider Demographics
NPI:1669965349
Name:PETIT AVE INC.
Entity type:Organization
Organization Name:PETIT AVE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAZARYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RRT, RCP
Authorized Official - Phone:818-945-4374
Mailing Address - Street 1:6719 QUAKERTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-4336
Mailing Address - Country:US
Mailing Address - Phone:818-945-4374
Mailing Address - Fax:818-435-3079
Practice Address - Street 1:6719 QUAKERTOWN AVE
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-4336
Practice Address - Country:US
Practice Address - Phone:818-945-4374
Practice Address - Fax:818-435-3079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility