MEDICARE: ELITE DIAGNOSTIC IMAGING INC

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	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1215189287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE DIAGNOSTIC IMAGING INC

Provider Business Mailing Address
First Line	:	6164 TONY AVE
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-1249
Country	:	US
Telephone Number	:	818-719-0080
Fax Number	:	818-719-0088

Provider Business Practice Location Address
First Line	:	6164 TONY AVE
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-1249
Country	:	US
Telephone Number	:	818-719-0080
Fax Number	:	818-719-0088

Authorized Official
Title or Position	:	CEO
Name	:	ROSS TSYMBALOV
Credential	:
Telephone Number	:	818-719-0080

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	01/27/2011

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