1184672875 NPI number — LIBERTY PACIFIC MEDICAL IMAGING ENCINO, LLC

Table of content: (NPI 1184672875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184672875 NPI number — LIBERTY PACIFIC MEDICAL IMAGING ENCINO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY PACIFIC MEDICAL IMAGING ENCINO, LLC
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:
1184672875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORESTHILL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95631-1279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-367-5295
Provider Business Mailing Address Fax Number:
530-367-4634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16130 VENTURA BLVD
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91436-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-933-2020
Provider Business Practice Location Address Fax Number:
818-933-2021
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KAVON
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
(NONE)
Authorized Official Title or Position:
V.P. MARKETING & CONTRACTING
Authorized Official Telephone Number:
530-367-5295

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com