Healthcare Provider Details

I. General information

NPI: 1598749921
Provider Name (Legal Business Name): RENAISSANCE RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SAN BERNARDINO ST
MONTCLAIR CA
91763-2326
US

IV. Provider business mailing address

1902 ROYALTY DR SUITE 220
POMONA CA
91767-3030
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-8180
  • Fax: 909-469-6741
Mailing address:
  • Phone: 909-620-8180
  • Fax: 909-469-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. MONIKA KIEF GARCIA
Title or Position: PRESIDENT CEO
Credential: M.D.
Phone: 909-620-8180