Healthcare Provider Details

I. General information

NPI: 1023185428
Provider Name (Legal Business Name): LA JOLLA RADIOLOGY MEDICAL GROUP THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 02/01/2008
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

916 SYCAMORE AVE
VISTA CA
92081-7815
US

V. Phone/Fax

Practice location:
  • Phone: 760-599-9545
  • Fax: 760-599-9549
Mailing address:
  • Phone: 760-599-9545
  • Fax: 760-599-9549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: ELIZABETH BOURBEAU
Title or Position: MANAGER
Credential:
Phone: 760-599-9545