Healthcare Provider Details

I. General information

NPI: 1194868828
Provider Name (Legal Business Name): ELECTRONIC ORTHOPEDIC IMAGING MEDICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10921 WILSHIRE BLVD 2ND FLOOR
LOS ANGELES CA
90024-3906
US

IV. Provider business mailing address

PO BOX 190
SIMI VALLEY CA
93062-0190
US

V. Phone/Fax

Practice location:
  • Phone: 310-208-3100
  • Fax:
Mailing address:
  • Phone: 805-522-5940
  • Fax: 805-522-6401

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: JERROLD MINK
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 310-208-3100