Provider Demographics
NPI:1134275951
Name:AVANESIAN, AIDA (LAC)
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:AVANESIAN
Suffix:
Gender:F
Credentials:LAC
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 304
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029
Mailing Address - Country:US
Mailing Address - Phone:323-953-1000
Mailing Address - Fax:323-953-1000
Practice Address - Street 1:201 N BELMONT ST
Practice Address - Street 2:APT 104
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4925
Practice Address - Country:US
Practice Address - Phone:818-484-6342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11057171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0110570Medicaid