Provider Demographics
NPI:1306276993
Name:GABRIEL RUBANENKO, INC., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:GABRIEL RUBANENKO, INC., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:RUBANENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-965-5088
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 910
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-965-5088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GABRIEL RUBANENKO, INC., A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39466332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site