Provider Demographics
NPI:1285776237
Name:MIKWAVES DIAGNOSTIC INC
Entity type:Organization
Organization Name:MIKWAVES DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-509-8808
Mailing Address - Street 1:11120 BURBANK BLVD
Mailing Address - Street 2:SPACE 1A
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-5708
Mailing Address - Country:US
Mailing Address - Phone:818-509-8808
Mailing Address - Fax:818-509-8806
Practice Address - Street 1:11120 BURBANK BLVD
Practice Address - Street 2:SPACE 1A
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-5708
Practice Address - Country:US
Practice Address - Phone:818-509-8808
Practice Address - Fax:818-509-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0002055859-0001-1261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty