Healthcare Provider Details

I. General information

NPI: 1265342703
Provider Name (Legal Business Name): PROVISION MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19702 SKYVIEW CT
SANTA CLARITA CA
91351-6900
US

IV. Provider business mailing address

19702 SKYVIEW CT
SANTA CLARITA CA
91351-6900
US

V. Phone/Fax

Practice location:
  • Phone: 661-383-3477
  • Fax:
Mailing address:
  • Phone: 661-383-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: JUNAIDA SHAKHVALADYAN
Title or Position: CEO
Credential:
Phone: 661-383-3477