Healthcare Provider Details

I. General information

NPI: 1710801220
Provider Name (Legal Business Name): OMEGA DIAGNOSTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5176 SANTA MONICA BLVD STE 106
LOS ANGELES CA
90029-2586
US

IV. Provider business mailing address

5176 SANTA MONICA BLVD STE 106
LOS ANGELES CA
90029-2586
US

V. Phone/Fax

Practice location:
  • Phone: 213-258-5965
  • Fax: 213-258-5966
Mailing address:
  • Phone: 213-258-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL

VIII. Authorized Official

Name: RASAMBEK KHATCHIEV
Title or Position: CEO,CFO
Credential:
Phone: 213-258-5965