1104931864 NPI number — MIRACOR DIAGNOSTICS, INC.

Table of content: (NPI 1104931864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104931864 NPI number — MIRACOR DIAGNOSTICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACOR DIAGNOSTICS, 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:
LONG BEACH MEDICAL IMAGING CENTER
Provider Other Organization Name Type Code:
3
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:
1104931864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 W PARKVIEW TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALGONQUIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60102-1950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-658-0996
Provider Business Mailing Address Fax Number:
847-658-0991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 E PACIFIC COAST HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90804-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-498-6322
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSINSKI
Authorized Official First Name:
GAELANE
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTING/CREDENTIALING SPECIALIS
Authorized Official Telephone Number:
847658006

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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