1689965774 NPI number — PROFESSIONAL MAMMOGRAPHY IMAGING, INC.

Table of content: (NPI 1689965774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689965774 NPI number — PROFESSIONAL MAMMOGRAPHY IMAGING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL MAMMOGRAPHY IMAGING, 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:
1689965774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18429 SHERMAN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RESEDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91335-4358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-343-6009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18429 SHERMAN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91335-4358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-343-6009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GASPARYAN
Authorized Official First Name:
KARINE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-343-6009

Provider Taxonomy Codes

  • Taxonomy code: 2471M2300X , with the licence number:  238079 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471S1302X , with the licence number: 36356 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 238079 . This is a "MAMMOGRAPHY FACILITY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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