Provider Demographics
NPI:1407963093
Name:VICTORVILLE OPENSCAN MRI
Entity Type:Organization
Organization Name:VICTORVILLE OPENSCAN MRI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-303-2776
Mailing Address - Street 1:2200 ROSS AVE
Mailing Address - Street 2:3600 CHASE TOWER
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2708
Mailing Address - Country:US
Mailing Address - Phone:214-303-2776
Mailing Address - Fax:
Practice Address - Street 1:12276 HESPERIA RD STE 6
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5838
Practice Address - Country:US
Practice Address - Phone:760-843-0995
Practice Address - Fax:760-843-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18873ZMedicare ID - Type Unspecified