Provider Demographics
NPI:1164679718
Name:CANYON MEDICAL CENTER CORPORATION
Entity Type:Organization
Organization Name:CANYON MEDICAL CENTER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VESCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-880-0799
Mailing Address - Street 1:4937 LAS VIRGENES RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-2949
Mailing Address - Country:US
Mailing Address - Phone:818-880-0799
Mailing Address - Fax:818-880-6689
Practice Address - Street 1:4937 LAS VIRGENES RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-2949
Practice Address - Country:US
Practice Address - Phone:818-880-0799
Practice Address - Fax:818-880-6689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43384A207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11585Medicare PIN