=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871549899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUEBLO RADIOLOGY MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W PUEBLO ST
-----------------------------------------------------
City | SANTA BARBARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93105-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-682-7744
-----------------------------------------------------
Fax | 805-682-3321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | DEPT LA 21613
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91185-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-263-8620
-----------------------------------------------------
Fax | 949-263-1639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LAWRENCE HARTER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-682-7984
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------