Provider Demographics
NPI:1578588323
Name:UNIVERSAL OPEN MRI AND DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:UNIVERSAL OPEN MRI AND DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-325-9901
Mailing Address - Street 1:1403 LOMITA BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2076
Mailing Address - Country:US
Mailing Address - Phone:310-325-9901
Mailing Address - Fax:310-325-0202
Practice Address - Street 1:1100 SHERMAN AVE STE 110
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4855
Practice Address - Country:US
Practice Address - Phone:310-325-9901
Practice Address - Fax:310-325-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL81295Medicare PIN
IL594580Medicare PIN