Healthcare Provider Details

I. General information

NPI: 1699729848
Provider Name (Legal Business Name): VANOWEN RADIOLOGICAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

IV. Provider business mailing address

PO BOX 190
SIMI VALLEY CA
93062-0190
US

V. Phone/Fax

Practice location:
  • Phone: 818-902-2951
  • Fax:
Mailing address:
  • Phone: 805-522-5940
  • Fax: 805-522-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LARRY KUSSIN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 818-902-2951