Provider Demographics
NPI:1316361785
Name:OLIVE BRANCH DIAGNOSTIC IMAGING, INC
Entity Type:Organization
Organization Name:OLIVE BRANCH DIAGNOSTIC IMAGING, INC
Other - Org Name:OLIVE BRANCH IMAGING
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:909-332-3334
Mailing Address - Street 1:10808 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 160-602
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3889
Mailing Address - Country:US
Mailing Address - Phone:909-332-3334
Mailing Address - Fax:909-233-3925
Practice Address - Street 1:10722 ARROW RTE
Practice Address - Street 2:SUITE 520
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4808
Practice Address - Country:US
Practice Address - Phone:909-332-3334
Practice Address - Fax:909-233-3925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1181332471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty