Basic Information
| Provider Information | |||||||||
| NPI: | 1497125272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANTAR | ||||||||
| FirstName: | VICTORIA | ||||||||
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| Credential: | C.R.T (R)(M)(F) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 E MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902452424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012133648 | ||||||||
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| Practice Location | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3402X | RHM00069343 | CA | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography | 2471M2300X | RHM00069343 | CA | Y | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Mammography |
No ID Information.