=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629502877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GNA DIAGNOSTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2017
-----------------------------------------------------
Last Update Date | 04/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1480 COLORADO BLVD # 135
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90041-2357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-281-8091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 COLORADO BLVD #135
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-281-8091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GRANT KOSTIKIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-281-8091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1200X
-----------------------------------------------------
Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------