Healthcare Provider Details

I. General information

NPI: 1649441858
Provider Name (Legal Business Name): LJR NEURO INTERVENTIONAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9888 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

10150 SORRENTO VALLEY RD SUITE 320
SAN DIEGO CA
92121-1635
US

V. Phone/Fax

Practice location:
  • Phone: 858-626-6884
  • Fax:
Mailing address:
  • Phone: 858-454-4235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER H.B. MCCREIGHT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-454-4235