=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366560724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAINSTREAM VASCULAR DIAGNOSTIC IMAGING LABORATORIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1315 ALHAMBRA BLVD SUITE 320
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-5244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-736-6033
-----------------------------------------------------
Fax | 916-736-6034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 ALHAMBRA BLVD SUITE 320
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-5244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-736-6033
-----------------------------------------------------
Fax | 916-736-6034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRADEN JARED VICTOR
-----------------------------------------------------
Credential | B.S., R.V.T.
-----------------------------------------------------
Telephone | 916-736-6033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246XC2903X
-----------------------------------------------------
Taxonomy Name | Vascular Specialist/Technologist Cardiovascular
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------