Provider Demographics
NPI:1841438074
Name:WHITTIER BREAST IMAGING PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:WHITTIER BREAST IMAGING PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-698-0811
Mailing Address - Street 1:PO BOX 1277
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-1277
Mailing Address - Country:US
Mailing Address - Phone:562-906-6470
Mailing Address - Fax:562-946-9465
Practice Address - Street 1:12393 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2502
Practice Address - Country:US
Practice Address - Phone:562-907-0667
Practice Address - Fax:562-907-4162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA704072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA70407OtherLICENSE