Healthcare Provider Details

I. General information

NPI: 1710484399
Provider Name (Legal Business Name): CHILDREN'S HEART CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N CENTRAL AVE STE 250
GLENDALE CA
91203-2061
US

IV. Provider business mailing address

12025 NEW DOMINION PKWY APT 307
RESTON VA
20190-6267
US

V. Phone/Fax

Practice location:
  • Phone: 818-839-7101
  • Fax:
Mailing address:
  • Phone: 571-405-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number145986
License Number StateCA

VIII. Authorized Official

Name: DR. GEORGIOS A. HARTAS
Title or Position: PRESIDENT
Credential: MD
Phone: 571-405-4012