Basic Information
| Provider Information | |||||||||
| NPI: | 1053456061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOTHER LODE DIAGNOSTIC IMAGING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5617 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486030617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092621845 | ||||||||
| FaxNumber: | 9894014235 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956422564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092230949 | ||||||||
| FaxNumber: | 2092230965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | BATXER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2092237560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0043480 | 05 | CA | MEDICAID |