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General NPI Number Information
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NPI Number | 1316361785
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Entity Type | Organization
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Legal Business Name | OLIVE BRANCH DIAGNOSTIC IMAGING, INC
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Dates
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Enumeration Date | 02/06/2014
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Last Update Date | 02/06/2014
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Provider Practice Location Address
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Address Line | 10722 ARROW RTE SUITE 520
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-4808
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Country | US
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Telephone | 909-332-3334
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Fax | 909-233-3925
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Provider Business Mailing Address
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Address Line | 10808 FOOTHILL BLVD SUITE 160-602
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3889
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Country | US
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Telephone | 909-332-3334
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Fax | 909-233-3925
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Authorized Official
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Title or Position | OWNER
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Name | TASHA STOKES
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Credential | RDMS
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Telephone | 909-332-3334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471S1302X
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Taxonomy Name | Sonography Radiologic Technologist
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License Number | 118133
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License Number State | CA
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