Provider Demographics
NPI:1356396170
Name:MEDLINE DIAGNOSTIC CENTER, INC
Entity type:Organization
Organization Name:MEDLINE DIAGNOSTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANASSENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-254-8600
Mailing Address - Street 1:1720 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1338
Mailing Address - Country:US
Mailing Address - Phone:323-254-8600
Mailing Address - Fax:323-254-8700
Practice Address - Street 1:1720 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1338
Practice Address - Country:US
Practice Address - Phone:323-254-8600
Practice Address - Fax:323-254-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG569Medicare ID - Type Unspecified