Provider Demographics
NPI:1568485522
Name:POMONA VALLEY IMAGING GROUP
Entity Type:Organization
Organization Name:POMONA VALLEY IMAGING GROUP
Other - Org Name:POMONA VALLEY HOSPITAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF RADIOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNSON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTFOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-865-9535
Mailing Address - Street 1:6134 GEANIE CT
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-6364
Mailing Address - Country:US
Mailing Address - Phone:909-630-7480
Mailing Address - Fax:909-397-0194
Practice Address - Street 1:1798 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2918
Practice Address - Country:US
Practice Address - Phone:909-630-7480
Practice Address - Fax:909-397-0194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG358762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46508Medicare UPIN