Provider Demographics
NPI:1548982853
Name:AVANESSIAN, TENIE
Entity type:Individual
Prefix:
First Name:TENIE
Middle Name:
Last Name:AVANESSIAN
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 1:1631 SANTA BARBARA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2020
Mailing Address - Country:US
Mailing Address - Phone:818-216-9866
Mailing Address - Fax:
Practice Address - Street 1:1059 GAYLEY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3401
Practice Address - Country:US
Practice Address - Phone:310-208-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35209152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist