Provider Demographics
NPI:1982667911
Name:POMONA VALLEY IMAGING MEDICAL GROUP INC
Entity Type:Organization
Organization Name:POMONA VALLEY IMAGING MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNSON
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:LIGHTFOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-825-9535
Mailing Address - Street 1:1798 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2918
Mailing Address - Country:US
Mailing Address - Phone:909-865-9535
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:909-825-9535
Practice Address - Fax:909-397-0194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID