1689635971 NPI number — FULLY OPEN MRI OF RANCHO BERNARDO LLC DBA POMERADO IMAGING

Table of content: (NPI 1689635971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689635971 NPI number — FULLY OPEN MRI OF RANCHO BERNARDO LLC DBA POMERADO IMAGING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FULLY OPEN MRI OF RANCHO BERNARDO LLC DBA POMERADO IMAGING
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:
6
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:
1689635971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 460875
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESCONDIDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92046-0875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-520-8500
Provider Business Mailing Address Fax Number:
760-520-8523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15725 POMERADO RD
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
POWAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92064-2068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-485-6094
Provider Business Practice Location Address Fax Number:
858-485-6059
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLANSKY
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
760-520-8500

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  3184 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1200X , with the licence number: 3184 , 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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