Provider Demographics
NPI:1568426518
Name:CENTER FOR OUPATIENT IMAGING, L.L.C.
Entity Type:Organization
Organization Name:CENTER FOR OUPATIENT IMAGING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-324-8033
Mailing Address - Street 1:1425 S GREENFIELD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-5505
Mailing Address - Country:US
Mailing Address - Phone:480-324-8033
Mailing Address - Fax:480-324-8038
Practice Address - Street 1:1425 S GREENFIELD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5505
Practice Address - Country:US
Practice Address - Phone:480-324-8033
Practice Address - Fax:480-324-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QR0200X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Not Answered261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0717920OtherBLUE CROSS ID
AZ2Z0812OtherHEALTH NET
AZ724874Medicaid
AZ2Z0812OtherHEALTH NET