Healthcare Provider Details

I. General information

NPI: 1932516754
Provider Name (Legal Business Name): ADVANCED IMAGING OF TRACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 WEST I STREET
LOS BANOS CA
95336-5964
US

IV. Provider business mailing address

PO BOX 398076
SAN FRANCISCO CA
94139-8076
US

V. Phone/Fax

Practice location:
  • Phone: 209-833-2393
  • Fax:
Mailing address:
  • Phone: 209-833-2393
  • Fax:

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: RICHARD M PORZIO
Title or Position: MD/PRESIDENT
Credential:
Phone: 209-833-2393