Provider Demographics
NPI:1053456061
Name:MOTHER LODE DIAGNOSTIC IMAGING INC
Entity Type:Organization
Organization Name:MOTHER LODE DIAGNOSTIC IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BATXER
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-223-7560
Mailing Address - Street 1:PO BOX 5617
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-0617
Mailing Address - Country:US
Mailing Address - Phone:209-262-1845
Mailing Address - Fax:989-401-4235
Practice Address - Street 1:200 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2564
Practice Address - Country:US
Practice Address - Phone:209-223-0949
Practice Address - Fax:209-223-0965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0043480Medicaid
ZZZ22192ZMedicare ID - Type Unspecified