Healthcare Provider Details

I. General information

NPI: 1356617096
Provider Name (Legal Business Name): MY IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 E ALVARADO ST STE D
FALLBROOK CA
92028-2350
US

IV. Provider business mailing address

5757 WILSHIRE BLVD STE 100
LOS ANGELES CA
90036-3686
US

V. Phone/Fax

Practice location:
  • Phone: 760-689-6100
  • Fax: 760-689-6110
Mailing address:
  • Phone: 323-648-0500
  • Fax: 323-648-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. PERLA I NUNEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 323-648-0500