Provider Demographics
NPI:1598867426
Name:REDWOOD RADIOLOGY IMAGING MEDICAL CLINIC
Entity type:Organization
Organization Name:REDWOOD RADIOLOGY IMAGING MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LINDSAY
Authorized Official - Last Name:VILTRAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:707-768-1988
Mailing Address - Street 1:PO BOX 6640
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6640
Mailing Address - Country:US
Mailing Address - Phone:707-768-1988
Mailing Address - Fax:
Practice Address - Street 1:3300 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3120
Practice Address - Country:US
Practice Address - Phone:707-725-3361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG723572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079730Medicaid
CAGR0079730Medicaid