Healthcare Provider Details

I. General information

NPI: 1689205049
Provider Name (Legal Business Name): CALIFORNIA NEUROENDOVASCULAR SPECIALISTS MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N LAKE AVE STE 800
PASADENA CA
91101-1857
US

IV. Provider business mailing address

530 S LAKE AVE # 439
PASADENA CA
91101-3515
US

V. Phone/Fax

Practice location:
  • Phone: 562-491-9270
  • Fax:
Mailing address:
  • Phone: 562-522-5304
  • Fax: 562-491-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WLED WAZNI
Title or Position: PRESIDENT
Credential: MD
Phone: 562-522-5304