=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275799231
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSOLIDATED IMAGING OF WINNETKA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 09/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7111 WINNETKA AVE SUITE 16
-----------------------------------------------------
City | CANOGA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91306-3646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-436-7409
-----------------------------------------------------
Fax | 818-436-7513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7111 WINNETKA AVENUE SUITE # 16
-----------------------------------------------------
City | CANOGA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91306-3646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-436-7409
-----------------------------------------------------
Fax | 818-436-7513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CAROLYN C. MORREALE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-908-2555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------