1275523169 NPI number — CENTRAL VALLEY IMAGING MEDICAL ASSOCIATES, INC

Table of content: (NPI 1275523169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275523169 NPI number — CENTRAL VALLEY IMAGING MEDICAL ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL VALLEY IMAGING MEDICAL ASSOCIATES, 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:
1275523169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 398076
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94139-8076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-647-2184
Provider Business Mailing Address Fax Number:
209-647-4684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 CHERRY LN STE 116
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95337-4398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-647-2184
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PORZIO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-647-2184

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  71935 , 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)

  • Identifier: GR0092114 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ65959Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0092113 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ08287Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0092110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0092111 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ05093Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ05094Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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