=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538276852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COURT STREET IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1755 COURT ST
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-241-8633
-----------------------------------------------------
Fax | 530-241-9020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1755 COURT ST
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-241-8633
-----------------------------------------------------
Fax | 530-241-9020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MR. WADE NAKATANI
-----------------------------------------------------
Credential | RHF
-----------------------------------------------------
Telephone | 530-241-8633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | RHT60057
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------