=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801655709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENCINO DIAGNOSTIC IMAGING INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2024
-----------------------------------------------------
Last Update Date | 10/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16661 VENTURA BLVD STE 100
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-595-8687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39120 ARGONAUT WAY STE 827
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | PUNEET CHANDAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-595-8687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207U00000X
-----------------------------------------------------
Taxonomy Name | Nuclear Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------