=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043372139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAMONA MEDICAL DIAGNOSTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1516 MAIN ST SUITE 103
-----------------------------------------------------
City | RAMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92065-5242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-789-6118
-----------------------------------------------------
Fax | 760-788-2068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1516 MAIN ST SUITE 103
-----------------------------------------------------
City | RAMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92065-5242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-789-6118
-----------------------------------------------------
Fax | 760-788-2068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. CHARLES FRALEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-789-6118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------