Provider Demographics
NPI:1306102165
Name:UNIVERSAL DIAGNOSTIC & IMAGING, INC.
Entity type:Organization
Organization Name:UNIVERSAL DIAGNOSTIC & IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-222-5855
Mailing Address - Street 1:5152 SEPULVEDA BLVD STE 117
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5152 SEPULVEDA BLVD STE 117
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1154
Practice Address - Country:US
Practice Address - Phone:747-222-5855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory