Healthcare Provider Details

I. General information

NPI: 1558550129
Provider Name (Legal Business Name): LAKE SIDE DIAGNOSTICS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6908 VARNA AVE
VALLEY GLEN CA
91405-4358
US

IV. Provider business mailing address

6908 VARNA AVE
VALLEY GLEN CA
91405-4358
US

V. Phone/Fax

Practice location:
  • Phone: 818-985-1999
  • Fax: 818-985-1222
Mailing address:
  • Phone: 818-985-1999
  • Fax: 818-985-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number StateCA

VIII. Authorized Official

Name: YEVGENY KANZBURG
Title or Position: PRESIDENT
Credential:
Phone: 818-985-1999