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General NPI Number Information
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NPI Number | 1154520989
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Entity Type | Organization
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Legal Business Name | GRAND AVENUE IMAGING
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Dates
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Enumeration Date | 07/12/2007
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 1400 S GRAND AVE STE 608
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City | LOS ANGELES
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State | CA
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Zip | 90015-3068
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Country | US
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Telephone | 213-746-5800
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Fax | 213-746-5802
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Provider Business Mailing Address
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Address Line | 1400 S GRAND AVE STE 608
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City | LOS ANGELES
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State | CA
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Zip | 90015-3068
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Country | US
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Telephone | 213-746-5800
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Fax | 213-746-5802
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. GENE EASON
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Credential |
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Telephone | 213-746-5800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0206X
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Taxonomy Name | Mammography Clinic/Center
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License Number | FAC 48220
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License Number State | CA
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