Healthcare Provider Details

I. General information

NPI: 1629109095
Provider Name (Legal Business Name): GRAND CANYON MEDICAL IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 STOCKTON HILL RD
KINGMAN AZ
86401-3619
US

IV. Provider business mailing address

PO BOX 73878
SAN CLEMENTE CA
92673-0130
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-0620
  • Fax:
Mailing address:
  • Phone: 714-754-5804
  • Fax: 714-754-6800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateAZ

VIII. Authorized Official

Name: WILLIAM R BURGE
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 714-754-5800