Basic Information
Provider Information | |||||||||
NPI: | 1760492458 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLIANCE HEALTHCARE SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 BAYVIEW CIRCLE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | NEWPORT BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 926602984 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005443215 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 210 W SAN BERNARDINO RD | ||||||||
Address2: |   | ||||||||
City: | COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917231515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263317331 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 10/04/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AIHARA | ||||||||
AuthorizedOfficialFirstName: | HOWARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXEC VP &CFO | ||||||||
AuthorizedOfficialTelephone: | 8005443215 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
ID | Type | State | Issuer | Description | 470000284 | 01 | CA | RAILROAD MEDICARE | OTHER | ZZZ00506Z | 01 | CA | BLUE SHIELD | OTHER | IDTF00460 | 05 | CA |   | MEDICAID | 470001394 | 01 | CA | RAILROAD MEDICARE | OTHER | ZZZ00504Z | 01 | CA | BLUE SHIELD | OTHER |