=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609675404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VEGA MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2025
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 N PACIFIC AVE STE 204
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91202-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-240-6912
-----------------------------------------------------
Fax | 747-240-6913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 N PACIFIC AVE STE 204
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91202-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 747-240-6912
-----------------------------------------------------
Fax | 747-240-6913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | VIGHEN MKRTOUMIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 747-240-6912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------