1659069672 NPI number — NORTHERN CALIFORNIA P.E.T. IMAGING CENTER

Table of content: (NPI 1659069672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659069672 NPI number — NORTHERN CALIFORNIA P.E.T. IMAGING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN CALIFORNIA P.E.T. IMAGING CENTER
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:
1659069672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3195 FOLSOM BLVD STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-5264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-737-3211
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3718 ATHERTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKLIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95765-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-737-3211
Provider Business Practice Location Address Fax Number:
916-737-6203
Provider Enumeration Date:
04/27/2023

Additional Information

Authorized Official

Authorized Official Last Name:
HALEY
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
916-737-3214

Provider Taxonomy Codes

  • Taxonomy code: 207U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0088760 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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