Healthcare Provider Details

I. General information

NPI: 1083705081
Provider Name (Legal Business Name): RENOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE SUITE 210
GLENDALE CA
91204-2500
US

IV. Provider business mailing address

1510 S CENTRAL AVE SUITE 210
GLENDALE CA
91204-2500
US

V. Phone/Fax

Practice location:
  • Phone: 818-956-2111
  • Fax: 818-956-2122
Mailing address:
  • Phone: 818-956-2111
  • Fax: 818-956-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA24092
License Number StateCA

VIII. Authorized Official

Name: MRS. ANTOINETTE GRANILLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 818-956-2111