Healthcare Provider Details

I. General information

NPI: 1275612509
Provider Name (Legal Business Name): MRI HEALTHCARE CENTER OF GLENDALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 S CENTRAL AVE
GLENDALE CA
91204-2212
US

IV. Provider business mailing address

1056 TYLER LN
UPLAND CA
91784-9279
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-4646
  • Fax:
Mailing address:
  • Phone: 909-982-2985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG206170
License Number StateCA

VIII. Authorized Official

Name: DR. SEVERIANO VALENZUELA
Title or Position: RADIOLOGISTMEDICAL DIRECTOR
Credential: M.D.
Phone: 818-244-4646