Healthcare Provider Details

I. General information

NPI: 1750873998
Provider Name (Legal Business Name): LOS ROBLES RADIOLOGIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 ROSA WAY
CUMBERLAND ME
04021-3527
US

IV. Provider business mailing address

DEPT LA 21628
PASADENA CA
91185-1628
US

V. Phone/Fax

Practice location:
  • Phone: 559-455-4009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BARRY D KLEIN
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 559-455-4009