Healthcare Provider Details

I. General information

NPI: 1720957129
Provider Name (Legal Business Name): MEDICAL CENTER OF TOLUCA LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10718 RIVERSIDE DR UNIT A
NORTH HOLLYWOOD CA
91602-2313
US

IV. Provider business mailing address

10718 RIVERSIDE DR UNIT A UNIT A
NORTH HOLLYWOOD CA
91602-2313
US

V. Phone/Fax

Practice location:
  • Phone: 323-483-8888
  • Fax:
Mailing address:
  • Phone: 323-483-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: VARDAN TADEVOSYAN
Title or Position: CEO
Credential:
Phone: 323-483-8888