Healthcare Provider Details

I. General information

NPI: 1689965774
Provider Name (Legal Business Name): PROFESSIONAL MAMMOGRAPHY IMAGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18429 SHERMAN WAY
RESEDA CA
91335-4358
US

IV. Provider business mailing address

18429 SHERMAN WAY
RESEDA CA
91335-4358
US

V. Phone/Fax

Practice location:
  • Phone: 818-343-6009
  • Fax:
Mailing address:
  • Phone: 818-343-6009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number238079
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number36356
License Number StateCA

VIII. Authorized Official

Name: KARINE GASPARYAN
Title or Position: PRESIDENT
Credential: RT
Phone: 818-343-6009