Healthcare Provider Details

I. General information

NPI: 1346658556
Provider Name (Legal Business Name): ULTRASOUND INSTITUTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 INLAND EMPIRE BLVD SUITE 250
ONTARIO CA
91764-4906
US

IV. Provider business mailing address

3700 INLAND EMPIRE BLVD SUITE 250
ONTARIO CA
91764-4906
US

V. Phone/Fax

Practice location:
  • Phone: 909-483-5550
  • Fax: 909-483-5509
Mailing address:
  • Phone: 909-483-5550
  • Fax: 909-483-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA MARX
Title or Position: ADMINISTRATOR
Credential:
Phone: 909-483-5550