Healthcare Provider Details

I. General information

NPI: 1336201094
Provider Name (Legal Business Name): LIA GORELISHVILI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 FOOTHILL BLVD
SUNLAND CA
91040-2849
US

IV. Provider business mailing address

8340 FOOTHILL BLVD
SUNLAND CA
91040-2849
US

V. Phone/Fax

Practice location:
  • Phone: 818-446-0700
  • Fax: 818-446-0064
Mailing address:
  • Phone: 818-446-0700
  • Fax: 818-446-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5724590001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: