Provider Demographics
NPI:1619044534
Name:MAMMO Q PLUS INC
Entity Type:Organization
Organization Name:MAMMO Q PLUS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:TARROZA
Authorized Official - Last Name:VIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-518-2620
Mailing Address - Street 1:22020 S AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2734
Mailing Address - Country:US
Mailing Address - Phone:310-518-2620
Mailing Address - Fax:310-835-5799
Practice Address - Street 1:22020 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3307
Practice Address - Country:US
Practice Address - Phone:310-518-2620
Practice Address - Fax:310-835-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXR010016FMedicaid
CATG492Medicare ID - Type Unspecified