Provider Demographics
NPI:1740530765
Name:RADIOLOGY DISC OF MIRACLE MILE INC
Entity type:Organization
Organization Name:RADIOLOGY DISC OF MIRACLE MILE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOZAFFAR
Authorized Official - Middle Name:
Authorized Official - Last Name:REZVONPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-986-3472
Mailing Address - Street 1:16661 VENTURA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1922
Mailing Address - Country:US
Mailing Address - Phone:818-986-3472
Mailing Address - Fax:818-986-2129
Practice Address - Street 1:16661 VENTURA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1922
Practice Address - Country:US
Practice Address - Phone:818-986-3472
Practice Address - Fax:818-986-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty