Healthcare Provider Details

I. General information

NPI: 1457653206
Provider Name (Legal Business Name): RIVERSIDE RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 LAKETREE DR
FALLBROOK CA
92028-9404
US

IV. Provider business mailing address

1660 CHICAGO AVE SUITE M-17
RIVERSIDE CA
92507-2068
US

V. Phone/Fax

Practice location:
  • Phone: 559-455-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: DONALD R. MASSEE
Title or Position: PRESIDENT
Credential:
Phone: 951-781-2273