Provider Demographics
NPI:1689888653
Name:GNA DIAGNOSTIC
Entity Type:Organization
Organization Name:GNA DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTIKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-281-8091
Mailing Address - Street 1:1386 E GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2660
Mailing Address - Country:US
Mailing Address - Phone:818-281-8091
Mailing Address - Fax:
Practice Address - Street 1:1386 E GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2660
Practice Address - Country:US
Practice Address - Phone:818-281-8091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Not Answered261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID