Healthcare Provider Details

I. General information

NPI: 1386001261
Provider Name (Legal Business Name): LOS ANGELES HEMATOLOGY ONCOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER STE 200
GLENDALE CA
91206-4073
US

IV. Provider business mailing address

541 W COLORADO ST STE 205
GLENDALE CA
91204-3640
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-0105
  • Fax: 866-810-7504
Mailing address:
  • Phone: 323-254-0046
  • Fax: 323-488-9782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number5638537
License Number StateCA

VIII. Authorized Official

Name: MARLA LOU WSIAKI
Title or Position: PROJECT MANAGER
Credential:
Phone: 323-254-0046