Provider Demographics
NPI:1528219672
Name:CELLGENIX IMAGING SERVICES OF PHOENIX LLC
Entity Type:Organization
Organization Name:CELLGENIX IMAGING SERVICES OF PHOENIX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CORLLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:949-276-7155
Mailing Address - Street 1:29222 RANCHO VIEJO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1041
Mailing Address - Country:US
Mailing Address - Phone:949-276-7155
Mailing Address - Fax:949-276-7158
Practice Address - Street 1:4540 E COTTON GIN LOOP
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-8887
Practice Address - Country:US
Practice Address - Phone:949-276-7155
Practice Address - Fax:949-276-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ132505Medicare PIN