Provider Demographics
NPI:1366486136
Name:CALIFORNIA LOCAL DIAGNOSTIC,INC
Entity Type:Organization
Organization Name:CALIFORNIA LOCAL DIAGNOSTIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARYTUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOUDAGOULIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-244-0202
Mailing Address - Street 1:216 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1191
Mailing Address - Country:US
Mailing Address - Phone:818-244-0202
Mailing Address - Fax:
Practice Address - Street 1:216 S JACKSON ST
Practice Address - Street 2:SUITE # 101
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1177
Practice Address - Country:US
Practice Address - Phone:818-244-0202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATG226302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG226Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER