MEDICARE: GRAND AVENUE IMAGING

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	261QR0206X	Mammography Clinic/Center	FAC 48220	CA

General Provider Information

NPI Number	:	1154520989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND AVENUE IMAGING

Provider Business Mailing Address
First Line	:	1400 S GRAND AVE STE 608
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90015-3068
Country	:	US
Telephone Number	:	213-746-5800
Fax Number	:	213-746-5802

Provider Business Practice Location Address
First Line	:	1400 S GRAND AVE STE 608
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90015-3068
Country	:	US
Telephone Number	:	213-746-5800
Fax Number	:	213-746-5802

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. GENE EASON
Credential	:
Telephone Number	:	213-746-5800

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	06/21/2018

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Directions to “GRAND AVENUE IMAGING ” Practice Location

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