Provider Demographics
NPI:1841423159
Name:PRO WELLNESS DIAGNOSTIC SERVICES
Entity Type:Organization
Organization Name:PRO WELLNESS DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTAK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-508-6888
Mailing Address - Street 1:PO BOX 5998
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91221-5998
Mailing Address - Country:US
Mailing Address - Phone:818-508-6888
Mailing Address - Fax:818-508-6778
Practice Address - Street 1:11239 VENTURA BLVD
Practice Address - Street 2:215
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3163
Practice Address - Country:US
Practice Address - Phone:818-508-6888
Practice Address - Fax:818-508-6778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15628207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG15628Medicare Oscar/Certification