Provider Demographics
NPI:1740658152
Name:GOUGOULIAN, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GOUGOULIAN
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 1:1450 S HAVANA ST
Mailing Address - Street 2:# 707
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4018
Mailing Address - Country:US
Mailing Address - Phone:720-748-7843
Mailing Address - Fax:720-748-2174
Practice Address - Street 1:1450 S HAVANA ST
Practice Address - Street 2:# 707
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4018
Practice Address - Country:US
Practice Address - Phone:720-748-7843
Practice Address - Fax:720-748-2174
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO970221188172A00000X
376J00000X, 3747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider