Healthcare Provider Details

I. General information

NPI: 1104373745
Provider Name (Legal Business Name): INTEGRATIVE DIAGNOSTIC GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12231 ARTESIA BLVD
CERRITOS CA
90703-2750
US

IV. Provider business mailing address

1231 ARTESIA BLVD
CERRITOS CA
90703-2750
US

V. Phone/Fax

Practice location:
  • Phone: 562-653-0180
  • Fax: 562-402-3029
Mailing address:
  • Phone: 562-653-0180
  • Fax: 562-402-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA30411
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberPSY6247
License Number StateCA

VIII. Authorized Official

Name: MR. ANIL K GANGHI
Title or Position: PRESIDENT
Credential: MD.
Phone: 562-653-0180