Provider Demographics
NPI:1558550129
Name:LAKE SIDE DIAGNOSTICS CENTER, INC.
Entity Type:Organization
Organization Name:LAKE SIDE DIAGNOSTICS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YEVGENY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANZBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-985-1999
Mailing Address - Street 1:6908 VARNA AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4358
Mailing Address - Country:US
Mailing Address - Phone:818-985-1999
Mailing Address - Fax:818-985-1222
Practice Address - Street 1:6908 VARNA AVE
Practice Address - Street 2:
Practice Address - City:VALLEY GLEN
Practice Address - State:CA
Practice Address - Zip Code:91405-4358
Practice Address - Country:US
Practice Address - Phone:818-985-1999
Practice Address - Fax:818-985-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2471S1302X, 261QR0208X, 293D00000X
CA2471S1302X, 261QR0208X, 293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3311838Medicaid
CA3311838Medicaid