Provider Demographics
NPI:1255494795
Name:DIAGNOSTIC IMAGING MED GRP OF KENT
Entity Type:Organization
Organization Name:DIAGNOSTIC IMAGING MED GRP OF KENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADELAIDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BUSTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-413-7888
Mailing Address - Street 1:711 N ALVARADO STREET
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4016
Mailing Address - Country:US
Mailing Address - Phone:213-413-7888
Mailing Address - Fax:213-413-5986
Practice Address - Street 1:711 N ALVARADO STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4016
Practice Address - Country:US
Practice Address - Phone:213-413-7888
Practice Address - Fax:213-413-5986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA363482085R0202X
CAA393812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0029050Medicaid
CAGR0029050Medicaid