Provider Demographics
NPI:1952586125
Name:DAVTYAN, SHAKE (DC)
Entity Type:Individual
Prefix:
First Name:SHAKE
Middle Name:
Last Name:DAVTYAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE #307
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1252
Mailing Address - Country:US
Mailing Address - Phone:323-913-0339
Mailing Address - Fax:323-913-0339
Practice Address - Street 1:5250 SANTA MONICA BLVD
Practice Address - Street 2:SUITE #307
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1252
Practice Address - Country:US
Practice Address - Phone:323-913-0339
Practice Address - Fax:323-913-0339
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21935111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0219350Medicaid
CADC0219350Medicaid
CAU42809Medicare UPIN
CADC21935Medicare Oscar/Certification