Provider Demographics
NPI:1346489010
Name:EXECUTIVE MEDICAL DIAGNOSTICS
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHINIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-715-0505
Mailing Address - Street 1:31852 COAST HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-6764
Mailing Address - Country:US
Mailing Address - Phone:949-715-0505
Mailing Address - Fax:
Practice Address - Street 1:31852 COAST HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-6764
Practice Address - Country:US
Practice Address - Phone:949-715-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2823798293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory