Basic Information
| Provider Information | |||||||||
| NPI: | 1558960161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANTELOPE VALLEY OUTPATIENT IMAGING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930620190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555044544 | ||||||||
| FaxNumber: | 8055772018 | ||||||||
| Practice Location | |||||||||
| Address1: | 38209 47TH ST E STE D | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935523113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617266050 | ||||||||
| FaxNumber: | 6619514464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | MIRZABEGIAN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6619495533 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.