Provider Demographics
NPI:1598711046
Name:PROF.IMAGING GRPOUP, INC
Entity Type:Organization
Organization Name:PROF.IMAGING GRPOUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-821-7772
Mailing Address - Street 1:3540 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2316
Mailing Address - Country:US
Mailing Address - Phone:213-386-2942
Mailing Address - Fax:213-386-2942
Practice Address - Street 1:9914 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6108
Practice Address - Country:US
Practice Address - Phone:323-569-6979
Practice Address - Fax:323-249-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG562Medicare ID - Type Unspecified