Provider Demographics
NPI:1932293503
Name:KMG DIAGNOSTIC INC
Entity Type:Organization
Organization Name:KMG DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MESROP
Authorized Official - Middle Name:
Authorized Official - Last Name:KONANYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-548-5665
Mailing Address - Street 1:326 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1011
Mailing Address - Country:US
Mailing Address - Phone:818-548-5665
Mailing Address - Fax:818-548-5600
Practice Address - Street 1:326 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1011
Practice Address - Country:US
Practice Address - Phone:818-548-5665
Practice Address - Fax:818-548-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102175305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service