Provider Demographics
NPI:1225300775
Name:IMAGEN & CHRYSTAL INC
Entity Type:Organization
Organization Name:IMAGEN & CHRYSTAL INC
Other - Org Name:PV WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ENKHBAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:TSERENDORJ
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:310-530-0500
Mailing Address - Street 1:26640 WESTERN AVE STE K2
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3600
Mailing Address - Country:US
Mailing Address - Phone:310-530-0500
Mailing Address - Fax:310-530-0501
Practice Address - Street 1:26640 WESTERN AVE STE K2
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3600
Practice Address - Country:US
Practice Address - Phone:310-530-0500
Practice Address - Fax:310-530-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11091261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service