Provider Demographics
NPI:1225316284
Name:MAGNOLIA NEURODIAGNOSTIC INC
Entity Type:Organization
Organization Name:MAGNOLIA NEURODIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MILENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELKONYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-260-0595
Mailing Address - Street 1:4020 W MAGNOLIA BLVD
Mailing Address - Street 2:E
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2828
Mailing Address - Country:US
Mailing Address - Phone:818-260-0595
Mailing Address - Fax:818-260-8792
Practice Address - Street 1:4020 W MAGNOLIA BLVD
Practice Address - Street 2:E
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2828
Practice Address - Country:US
Practice Address - Phone:818-260-0595
Practice Address - Fax:818-260-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC43367Medicare Oscar/Certification