Healthcare Provider Details

I. General information

NPI: 1366486136
Provider Name (Legal Business Name): CALIFORNIA LOCAL DIAGNOSTIC,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S JACKSON ST SUITE # 101
GLENDALE CA
91205-1177
US

IV. Provider business mailing address

216 S JACKSON ST
GLENDALE CA
91205-1191
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-0202
  • Fax:
Mailing address:
  • Phone: 818-244-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberTG226
License Number StateCA

VIII. Authorized Official

Name: ARYTUN KHOUDAGOULIAN
Title or Position: PRESIDENT
Credential:
Phone: 818-244-0202