Healthcare Provider Details

I. General information

NPI: 1609834274
Provider Name (Legal Business Name): DIMITRI PETER YAGDJIS C.P.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16122 COVELLO ST
VAN NUYS CA
91406-2910
US

IV. Provider business mailing address

8629 KELVIN AVE
WINNETKA CA
91306-1254
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-5414
  • Fax: 818-988-5415
Mailing address:
  • Phone: 818-321-6829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCPO02371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: