Healthcare Provider Details

I. General information

NPI: 1154669984
Provider Name (Legal Business Name): INTEGRATED MANAGEMENT & DIAGNOSTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5790 MAGNOLIA AVE SUITE 201
RIVERSIDE CA
92506-1874
US

IV. Provider business mailing address

5790 MAGNOLIA AVE SUITE 201
RIVERSIDE CA
92506-1874
US

V. Phone/Fax

Practice location:
  • Phone: 951-368-0428
  • Fax: 951-378-0429
Mailing address:
  • Phone: 951-368-0428
  • Fax: 951-378-0429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVE WILDISH
Title or Position: CFO
Credential:
Phone: 951-368-0428