Provider Demographics
NPI:1023160850
Name:ST. GERMAIN MOBILE IMAGING, INC.
Entity type:Organization
Organization Name:ST. GERMAIN MOBILE IMAGING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:MARIANO
Authorized Official - Last Name:CODECIDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-940-1384
Mailing Address - Street 1:PO BOX 8211
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-8211
Mailing Address - Country:US
Mailing Address - Phone:661-940-1384
Mailing Address - Fax:661-940-1382
Practice Address - Street 1:43830 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4826
Practice Address - Country:US
Practice Address - Phone:661-940-1384
Practice Address - Fax:661-940-1382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54843174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIDTF00590Medicaid
CA223458OtherF.D.A.
CA223458OtherF.D.A.
CA=========OtherBLUE CROSS