Healthcare Provider Details

I. General information

NPI: 1083213151
Provider Name (Legal Business Name): ANTELOPE VALLEY OUTPATIENT IMAGING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44105 15TH ST W STE 100
LANCASTER CA
93534-4090
US

IV. Provider business mailing address

PO BOX 190
SIMI VALLEY CA
93062-0190
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-6050
  • Fax: 661-951-4464
Mailing address:
  • Phone: 855-504-4544
  • Fax: 805-577-2018

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: MR. EDWARD MIRZABEGIAN
Title or Position: MANAGER
Credential:
Phone: 661-949-5533