1689866931 NPI number — MAGNOLIA IMAGING MEDICAL GROUP, INC.

Table of content: DR. ASHLEY GODWIN BLANSETT MD (NPI 1477879955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689866931 NPI number — MAGNOLIA IMAGING MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA IMAGING MEDICAL GROUP, 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:
1689866931
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14571 MAGNOLIA ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92683-5575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-891-2259
Provider Business Mailing Address Fax Number:
714-890-7030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17070 COLIMA RD # G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HACIENDA HEIGHTS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91745-6781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-891-2259
Provider Business Practice Location Address Fax Number:
714-890-7030
Provider Enumeration Date:
08/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHUNG
Authorized Official First Name:
THANH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-891-2259

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  C42348 , 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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