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General NPI Number Information
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NPI Number | 1306276993
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Entity Type | Organization
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Legal Business Name | GABRIEL RUBANENKO, INC., A MEDICAL CORPORATION
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Dates
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Enumeration Date | 11/18/2013
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Last Update Date | 11/18/2013
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Provider Practice Location Address
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Address Line | 6200 WILSHIRE BLVD SUITE 910
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City | LOS ANGELES
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State | CA
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Zip | 90048-5801
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Country | US
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Telephone | 323-965-5088
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Fax |
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Provider Business Mailing Address
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Address Line | 2980 N BEVERLY GLEN CIR SUITE 301
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City | LOS ANGELES
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State | CA
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Zip | 90077-1726
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GABRIEL V. RUBANENKO
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Credential | M.D.
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Telephone | 323-965-5088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | A39466
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License Number State | CA
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