Provider Demographics
NPI:1578505202
Name:MINERAL KING RADIOLOGICAL MEDICAL GROUP, INC
Entity type:Organization
Organization Name:MINERAL KING RADIOLOGICAL MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTERILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-608-5238
Mailing Address - Street 1:1700 S COURT ST
Mailing Address - Street 2:STE F
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4929
Mailing Address - Country:US
Mailing Address - Phone:559-734-9244
Mailing Address - Fax:559-734-6932
Practice Address - Street 1:1700 S COURT ST
Practice Address - Street 2:STE F
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4929
Practice Address - Country:US
Practice Address - Phone:559-734-9244
Practice Address - Fax:559-734-6932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA167435282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ93902ZMedicare PIN
CAZZZ03355ZMedicare PIN
CAZZZ93903ZMedicare PIN