MEDICARE: KMG DIAGNOSTIC 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	305S00000X	Point of Service	102175	CA

General Provider Information

NPI Number	:	1932293503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMG DIAGNOSTIC INC

Provider Business Mailing Address
First Line	:	326 E BROADWAY BLVD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1011
Country	:	US
Telephone Number	:	818-548-5665
Fax Number	:	818-548-5600

Provider Business Practice Location Address
First Line	:	326 E BROADWAY BLVD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1011
Country	:	US
Telephone Number	:	818-548-5665
Fax Number	:	818-548-5600

Authorized Official
Title or Position	:	CEO
Name	:	MESROP KONANYAN
Credential	:
Telephone Number	:	818-548-5665

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	06/19/2008

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