Healthcare Provider Details

I. General information

NPI: 1316988256
Provider Name (Legal Business Name): RENAISSANCE RADIOLOGY MED GRP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date: 08/28/2007
Reactivation Date: 10/11/2007

III. Provider practice location address

550 N MONTEREY AVENUE
ONTARIO CA
91764-3318
US

IV. Provider business mailing address

1902 ROYALTY DRIVE SUITE 220
POMONA CA
91767
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 TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: MONIKA L KIEF GARCIA
Title or Position: PRESIDENT CEO
Credential:
Phone: 909-620-8180