Provider Demographics
NPI:1184672875
Name:LIBERTY PACIFIC MEDICAL IMAGING ENCINO, LLC
Entity Type:Organization
Organization Name:LIBERTY PACIFIC MEDICAL IMAGING ENCINO, LLC
Other - Org Name:LIBERTY PACIFIC MRI OF ENCINO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. MARKETING & CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:(NONE)
Authorized Official - Last Name:KAVON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-367-5295
Mailing Address - Street 1:PO BOX 1279
Mailing Address - Street 2:
Mailing Address - City:FORESTHILL
Mailing Address - State:CA
Mailing Address - Zip Code:95631-1279
Mailing Address - Country:US
Mailing Address - Phone:530-367-5295
Mailing Address - Fax:530-367-4634
Practice Address - Street 1:16130 VENTURA BLVD
Practice Address - Street 2:#100
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2503
Practice Address - Country:US
Practice Address - Phone:818-933-2020
Practice Address - Fax:818-933-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATD 090Medicare PIN