Healthcare Provider Details

I. General information

NPI: 1881165546
Provider Name (Legal Business Name): EOLB MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16927 VANOWEN ST STE 4
LAKE BALBOA CA
91406-4582
US

IV. Provider business mailing address

18180 ANDREA CIR N UNIT 5
NORTHRIDGE CA
91325-1107
US

V. Phone/Fax

Practice location:
  • Phone: 818-483-4717
  • Fax:
Mailing address:
  • Phone: 818-960-5334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: EUGENE OSTROVSKY
Title or Position: PRESIDENT/ MEDICAL DIRECTOR
Credential: M. D.
Phone: 818-960-5334