Healthcare Provider Details

I. General information

NPI: 1427743566
Provider Name (Legal Business Name): LYDIA CREEDON MRI TECHNOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24331 EL TORO RD STE 200
LAGUNA WOODS CA
92637-3116
US

IV. Provider business mailing address

24331 EL TORO RD STE 200
LAGUNA WOODS CA
92637-3116
US

V. Phone/Fax

Practice location:
  • Phone: 949-586-3200
  • Fax: 949-900-2116
Mailing address:
  • Phone: 949-586-3200
  • Fax: 949-900-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberI044564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: