Healthcare Provider Details

I. General information

NPI: 1255588273
Provider Name (Legal Business Name): KGV EASY LEASING CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 CHANDLER BLVD SUITE 102
VALLEY VILLAGE CA
91607-1941
US

IV. Provider business mailing address

12501 CHANDLER BLVD SUITE 102
VALLEY VILLAGE CA
91607-1941
US

V. Phone/Fax

Practice location:
  • Phone: 818-980-1171
  • Fax: 818-763-8750
Mailing address:
  • Phone: 818-980-1171
  • Fax: 818-763-8750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: GREGORY DAVIDOV
Title or Position: CEO
Credential:
Phone: 818-980-1171