MEDICARE: SAN BERNARDINO IMAGING LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center
2	261QR0206X	Mammography Clinic/Center
3	261QR0200X	Radiology Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00385820	OTHER	CA	RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1164423612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN BERNARDINO IMAGING LLC

Provider Business Mailing Address
First Line	:	1884 BUSINESS CENTER DR
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3457
Country	:	US
Telephone Number	:	909-890-4090
Fax Number	:	909-890-4051

Provider Business Practice Location Address
First Line	:	1884 BUSINESS CENTER DR
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3457
Country	:	US
Telephone Number	:	909-890-4090
Fax Number	:	909-890-4051

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MR. LAVELLE HARDIN
Credential	:
Telephone Number	:	615-344-8203

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	03/18/2008

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Directions to “SAN BERNARDINO IMAGING LLC ” Practice Location

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