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General NPI Number Information
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NPI Number | 1518014463
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Entity Type | Organization
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Legal Business Name | SAN FERNANDO VALLEY VASCULAR GROUP A MEDICAL CORPORATION
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 06/18/2024
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Provider Practice Location Address
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Address Line | 18840 VENTURA BLVD STE 100A
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City | TARZANA
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State | CA
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Zip | 91356-3301
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Country | US
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Telephone | 818-345-6126
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Fax | 818-345-5061
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Provider Business Mailing Address
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Address Line | 18840 VENTURA BLVD STE 100A
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City | TARZANA
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State | CA
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Zip | 91356-3301
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Country | US
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Telephone | 818-345-6126
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Fax | 818-345-5061
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Authorized Official
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Title or Position | DIRECTOR
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Name | LYDIA NASSOURA
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Credential |
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Telephone | 818-345-6126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A062315
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License Number State | CA
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