1417012147 NPI number — PRO-CARE DIAGNOSTIC SERVICES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417012147 NPI number — PRO-CARE DIAGNOSTIC SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO-CARE DIAGNOSTIC SERVICES INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417012147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 E WILSON AVE
Provider Second Line Business Mailing Address:
307
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91206-4351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-638-8580
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 E WILSON AVE
Provider Second Line Business Practice Location Address:
307
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91206-4351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-638-8580
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALYAN
Authorized Official First Name:
PIRUZA
Authorized Official Middle Name:
LISA
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
818-638-8580

Provider Taxonomy Codes

  • Taxonomy code: 2471V0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471S1302X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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