Basic Information
| Provider Information | |||||||||
| NPI: | 1609829290 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMTEK SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CALIFONRIA ADVANCED IMAGING AT ATHERTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843415 | ||||||||
| FaxNumber: | 4158830877 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 EL CAMINO REAL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ATHERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940273812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503643080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/18/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 4158843096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | GR000314U | 05 | CA | MEDICAID | P00080429 | 01 | CA | RAILROAD MEDICARE | OTHER |