MEDICARE: STOCKTON MRI & MOLECULAR IMAGING MEDICAL CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center	00A323210	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073558656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STOCKTON MRI & MOLECULAR IMAGING MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	2320 N CALIFORNIA ST
Second Line	:	SUITE 2
City	:	STOCKTON
State	:	CA
Zip	:	95204-5509
Country	:	US
Telephone Number	:	209-466-2000
Fax Number	:	209-466-2600

Provider Business Practice Location Address
First Line	:	2320 N CALIFORNIA ST
Second Line	:	SUITE B
City	:	STOCKTON
State	:	CA
Zip	:	95204-5506
Country	:	US
Telephone Number	:	209-466-2000
Fax Number	:	209-466-2600

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. STAN FRED DOBRETZ
Credential	:	B.S.R.T.
Telephone Number	:	209-466-2000

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	07/23/2014

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