Healthcare Provider Details

I. General information

NPI: 1386753515
Provider Name (Legal Business Name): ICARDIO CORPORATION A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 GLENVILLE DRIVE
LOS ANGELES CA
90035
US

IV. Provider business mailing address

1531 GLENVILLE DRIVE
LOS ANGELES CA
90035
US

V. Phone/Fax

Practice location:
  • Phone: 310-551-2750
  • Fax: 310-861-5620
Mailing address:
  • Phone: 310-551-2750
  • Fax: 310-861-5620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License NumberG76919
License Number StateCA

VIII. Authorized Official

Name: JOSHUA PENN
Title or Position: PRESIDENT
Credential: MD
Phone: 310-551-2750