Healthcare Provider Details

I. General information

NPI: 1063411460
Provider Name (Legal Business Name): PALM IMAGING INSTITUTE, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E 21ST ST
SAN BERNARDINO CA
92404-4815
US

IV. Provider business mailing address

399 E 21ST ST
SAN BERNARDINO CA
92404-4815
US

V. Phone/Fax

Practice location:
  • Phone: 909-882-2266
  • Fax: 909-881-7593
Mailing address:
  • Phone: 909-882-2266
  • Fax: 909-881-7593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA20947
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberG55682
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA84930
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28926
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 10673
License Number StateCA

VIII. Authorized Official

Name: MS. TANIE DONALDSON
Title or Position: OFFICE MANAGER
Credential: RN
Phone: 909-882-2266