Provider Demographics
NPI:1790187169
Name:MID VALLEY VASCULAR CENTER, INC
Entity Type:Organization
Organization Name:MID VALLEY VASCULAR CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:POLOSAJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-454-3638
Mailing Address - Street 1:4930 BALBOA BLVD
Mailing Address - Street 2:SUITE 261278
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-7001
Mailing Address - Country:US
Mailing Address - Phone:818-718-1600
Mailing Address - Fax:818-343-1612
Practice Address - Street 1:7640 TAMPA AVE
Practice Address - Street 2:SUITE 101A
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-1735
Practice Address - Country:US
Practice Address - Phone:818-718-1600
Practice Address - Fax:818-343-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty