Basic Information
| Provider Information | |||||||||
| NPI: | 1194079632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KOUROSH KHAMOOSHIAN M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14677 VIA BETTONA STE 110 | ||||||||
| Address2: | PMB 136 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921274809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586036576 | ||||||||
| FaxNumber: | 8584083844 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 GROSSMONT CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197406000 | ||||||||
| FaxNumber: | 8584083488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2012 | ||||||||
| LastUpdateDate: | 11/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | KHAMOOSHIAN | ||||||||
| AuthorizedOfficialFirstName: | KOUROSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / CEO | ||||||||
| AuthorizedOfficialTelephone: | 8586036576 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | A110901 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 310400000X | A110901 | CA | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | A110901 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | A110901 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.