MEDICARE: BALANCE DREAM DIAGNOSTIC 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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G62117	OTHER	CA	MEDICAL BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1265717938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCE DREAM DIAGNOSTIC INC

Provider Business Mailing Address
First Line	:	1915 W GLENOAKS BLVD
Second Line	:	101A
City	:	GLENDALE
State	:	CA
Zip	:	91201-1541
Country	:	US
Telephone Number	:	818-736-5511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1915 W GLENOAKS BLVD
Second Line	:	101A
City	:	GLENDALE
State	:	CA
Zip	:	91201-1541
Country	:	US
Telephone Number	:	818-736-5511
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXSANDER KARAPETYAN
Credential	:
Telephone Number	:	818-736-5511

Provider Enumeration Date	:	10/13/2011
Last Update Date	:	10/13/2011

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