Healthcare Provider Details

I. General information

NPI: 1700216249
Provider Name (Legal Business Name): MONTCLAIR MRI INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8891 CENTRAL AVE SUITE C
MONTCLAIR CA
91763-1618
US

IV. Provider business mailing address

PO BOX 351358
LOS ANGELES CA
90035-9758
US

V. Phone/Fax

Practice location:
  • Phone: 909-624-8910
  • Fax: 909-912-8033
Mailing address:
  • Phone: 909-624-8910
  • Fax: 909-912-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. HARRY GOLBAHAR
Title or Position: PRESIDENT
Credential:
Phone: 909-624-8910