1972557569 NPI number — VACAVILLE IMAGING CENTER MEDICAL

Table of content: (NPI 1972557569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972557569 NPI number — VACAVILLE IMAGING CENTER MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VACAVILLE IMAGING CENTER MEDICAL
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:
1972557569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1516 COTNER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025-3303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-445-2951
Provider Business Mailing Address Fax Number:
310-479-1459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NUT TREE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
VACAVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95687-4669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-452-7226
Provider Business Practice Location Address Fax Number:
707-452-8422
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERGER
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-445-2800

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)

  • Identifier: GR0051380 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ41407Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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