Healthcare Provider Details

I. General information

NPI: 1245283217
Provider Name (Legal Business Name): NORTH COAST IMAGING RADIOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36485 INLAND VALLEY DR
WILDOMAR CA
92595-9681
US

IV. Provider business mailing address

8605 SANTA MONICA BLVD PMB 25192
WEST HOLLYWOOD CA
90069-4109
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-9713
  • Fax: 951-677-9762
Mailing address:
  • Phone: 800-880-2973
  • Fax: 951-600-4493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON GARY BECK
Title or Position: MANAGER
Credential:
Phone: 909-347-9340