=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700178605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACE MEDICAL GROUP AND DIAGNOSTIC IMAGING INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2011
-----------------------------------------------------
Last Update Date | 05/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3875 WILSHIRE BLVD SUITE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-385-4535
-----------------------------------------------------
Fax | 213-385-0204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3875 WILSHIRE BLVD SUITE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-385-4535
-----------------------------------------------------
Fax | 213-385-0204
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. HOOSHANG TABIBIAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 213-385-4535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------