Provider Demographics
NPI:1699737478
Name:RIVERSIDE MEDICAL IMAGING, L.L.C.
Entity type:Organization
Organization Name:RIVERSIDE MEDICAL IMAGING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-250-4500
Mailing Address - Street 1:10111 HOLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3441
Mailing Address - Country:US
Mailing Address - Phone:951-352-0555
Mailing Address - Fax:951-352-9780
Practice Address - Street 1:10111 HOLE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3441
Practice Address - Country:US
Practice Address - Phone:951-352-0555
Practice Address - Fax:951-352-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory