MEDICARE: VAN NUYS DIAGNOSTIC SERVICES, 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	TG063	CA

General Provider Information

NPI Number	:	1093753204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN NUYS DIAGNOSTIC SERVICES, INC.

Provider Business Mailing Address
First Line	:	2300 HUNTINGTON DR
Second Line	:	#B
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2641
Country	:	US
Telephone Number	:	626-403-2702
Fax Number	:	626-403-2703

Provider Business Practice Location Address
First Line	:	2300 HUNTINGTON DR
Second Line	:	#B
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2641
Country	:	US
Telephone Number	:	626-237-0502
Fax Number	:	626-237-0503

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ALEXANDER BEREZOVSKY
Credential	:
Telephone Number	:	626-237-0502

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	03/23/2008

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