Provider Demographics
NPI:1356620512
Name:JACARANDA RADIOLOGY
Entity type:Organization
Organization Name:JACARANDA RADIOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LAKESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:VN
Authorized Official - Phone:760-956-2636
Mailing Address - Street 1:12021 JACARANDA AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4978
Mailing Address - Country:US
Mailing Address - Phone:760-956-5561
Mailing Address - Fax:
Practice Address - Street 1:12021 JACARANDA AVE STE 104
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4978
Practice Address - Country:US
Practice Address - Phone:760-956-5561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABRAHAM WILSON INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology