Healthcare Provider Details

I. General information

NPI: 1831657402
Provider Name (Legal Business Name): EXCEL IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2019
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18158 US HIGHWAY 18
APPLE VALLEY CA
92307-2202
US

IV. Provider business mailing address

11962 ALPINE DR
FONTANA CA
92337-9072
US

V. Phone/Fax

Practice location:
  • Phone: 323-819-5053
  • Fax:
Mailing address:
  • Phone: 323-819-5053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT TARACENA
Title or Position: CEO
Credential:
Phone: 323-819-5053