MEDICARE: SKY DIAGNOSTICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TG440	OTHER	CA	IDTF PROVIDER NUMBER

General Provider Information

NPI Number	:	1013931518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKY DIAGNOSTICS, INC.

Provider Business Mailing Address
First Line	:	1825 N GRAMERCY PL
Second Line	:	# 204
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-5870
Country	:	US
Telephone Number	:	323-466-5018
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 N GRAMERCY PL
Second Line	:	# 204
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-5870
Country	:	US
Telephone Number	:	323-466-5018
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALEX KOZONASHVILI
Credential	:
Telephone Number	:	323-610-1035

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	08/22/2020

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Directions to “SKY DIAGNOSTICS, INC. ” Practice Location

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