Basic Information
| Provider Information | |||||||||
| NPI: | 1093772444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KUMAR PORTABLE XRAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4978 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953524978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754575 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Practice Location | |||||||||
| Address1: | 3621 GLENCREST DR | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953558431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754575 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | KUMAR | ||||||||
| AuthorizedOfficialFirstName: | SANT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MR | ||||||||
| AuthorizedOfficialTelephone: | 2095754575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335V00000X | RHF20122 | CA | Y | Suppliers | Portable X-Ray Supplier |
ID Information
| ID | Type | State | Issuer | Description | XR0599710 | 05 | CA | MEDICAID |