Healthcare Provider Details

I. General information

NPI: 1790882231
Provider Name (Legal Business Name): ORANGE COAST RADIOLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1081 N CHINA LAKE BLVD
RIDGECREST CA
93555-3130
US

IV. Provider business mailing address

PO BOX 73878
SAN CLEMENTE CA
92673-0130
US

V. Phone/Fax

Practice location:
  • Phone: 760-446-0642
  • Fax:
Mailing address:
  • Phone: 949-206-6800
  • Fax: 949-206-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA31455
License Number StateCA

VIII. Authorized Official

Name: MICHAEL SHANGIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 714-754-5804