Basic Information
| Provider Information | |||||||||
| NPI: | 1194495465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOTSURYAN | ||||||||
| FirstName: | SARKIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DRIVE | ||||||||
| Address2: | MAIL STOP #3005 | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017702476 | ||||||||
| FaxNumber: | 4012694731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1820 W VERDUGO AVE | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915062150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7472617747 | ||||||||
| FaxNumber: | 8188411015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2021 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | SLD42161 | CA | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.