Healthcare Provider Details

I. General information

NPI: 1053456061
Provider Name (Legal Business Name): MOTHER LODE DIAGNOSTIC IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MISSION BLVD
JACKSON CA
95642-2564
US

IV. Provider business mailing address

PO BOX 5617
SAGINAW MI
48603-0617
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-0949
  • Fax: 209-223-0965
Mailing address:
  • Phone: 209-262-1845
  • Fax: 989-401-4235

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: BATXER RICHARDSON
Title or Position: PRESIDENT
Credential: MD
Phone: 209-223-7560