Healthcare Provider Details

I. General information

NPI: 1184672875
Provider Name (Legal Business Name): LIBERTY PACIFIC MEDICAL IMAGING ENCINO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16130 VENTURA BLVD #100
ENCINO CA
91436-2503
US

IV. Provider business mailing address

PO BOX 1279
FORESTHILL CA
95631-1279
US

V. Phone/Fax

Practice location:
  • Phone: 818-933-2020
  • Fax: 818-933-2021
Mailing address:
  • Phone: 530-367-5295
  • Fax: 530-367-4634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RENEE (NONE) KAVON
Title or Position: V.P. MARKETING & CONTRACTING
Credential:
Phone: 530-367-5295