MEDICARE: MOLECULAR IMAGING CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	042159	CA

General Provider Information

NPI Number	:	1689622060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOLECULAR IMAGING CORPORATION

Provider Business Mailing Address
First Line	:	9530 TOWNE CENTRE DR
Second Line	:	SUITE 120
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1981
Country	:	US
Telephone Number	:	858-642-0032
Fax Number	:	858-642-0032

Provider Business Practice Location Address
First Line	:	7777 MILLIKEN AVE
Second Line	:	SUITE 110
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-6780
Country	:	US
Telephone Number	:	909-948-8034
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. KENNETH C FREDERICK
Credential	:
Telephone Number	:	858-642-0032

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	09/06/2023

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