Provider Demographics
NPI:1093007502
Name:FALLBROOK DIAGNOSTICS
Entity Type:Organization
Organization Name:FALLBROOK DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PERLA
Authorized Official - Middle Name:I
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-689-6100
Mailing Address - Street 1:616 E ALVARADO ST STE D
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-2350
Mailing Address - Country:US
Mailing Address - Phone:760-689-6100
Mailing Address - Fax:
Practice Address - Street 1:616 E ALVARADO ST STE D
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-2350
Practice Address - Country:US
Practice Address - Phone:760-689-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73716261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare PIN