MEDICARE: CANYON MEDICAL CENTER CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	43384A	CA

General Provider Information

NPI Number	:	1164679718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON MEDICAL CENTER CORPORATION

Provider Business Mailing Address
First Line	:	4937 LAS VIRGENES RD
Second Line	:	SUITE 104
City	:	CALABASAS
State	:	CA
Zip	:	91302-2949
Country	:	US
Telephone Number	:	818-880-0799
Fax Number	:	818-880-6689

Provider Business Practice Location Address
First Line	:	4937 LAS VIRGENES RD
Second Line	:	SUITE 104
City	:	CALABASAS
State	:	CA
Zip	:	91302-2949
Country	:	US
Telephone Number	:	818-880-0799
Fax Number	:	818-880-6689

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID VESCO
Credential	:	MD
Telephone Number	:	818-880-0799

Provider Enumeration Date	:	08/26/2008
Last Update Date	:	11/14/2014

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