Provider Demographics
NPI:1073558656
Name:STOCKTON MRI & MOLECULAR IMAGING MEDICAL CENTER INC
Entity type:Organization
Organization Name:STOCKTON MRI & MOLECULAR IMAGING MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:DOBRETZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSRT
Authorized Official - Phone:209-466-2000
Mailing Address - Street 1:2320 N CALIFORNIA ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5509
Mailing Address - Country:US
Mailing Address - Phone:209-466-2000
Mailing Address - Fax:209-466-2600
Practice Address - Street 1:2320 N CALIFORNIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5506
Practice Address - Country:US
Practice Address - Phone:209-466-2000
Practice Address - Fax:209-466-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A323210261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099760Medicaid
CAGR0099760Medicaid