Healthcare Provider Details

I. General information

NPI: 1730366048
Provider Name (Legal Business Name): CYNTHIA KINGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31368 FLYING CLOUD DR
LAGUNA NIGUEL CA
92677-2717
US

IV. Provider business mailing address

1180 OLYMPIC DR SUITE 108
CORONA CA
92881-3393
US

V. Phone/Fax

Practice location:
  • Phone: 949-464-9263
  • Fax: 951-272-9924
Mailing address:
  • Phone: 951-278-5590
  • Fax: 951-272-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0207X
TaxonomyMobile Mammography Clinic/Center
License Number45265
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: CNYTHIA KINGERY
Title or Position: OWNER/PRESIDENT
Credential: R.T.
Phone: 951-278-5590