Provider Demographics
NPI:1730366048
Name:CYNTHIA KINGERY
Entity type:Organization
Organization Name:CYNTHIA KINGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CNYTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGERY
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:951-278-5590
Mailing Address - Street 1:1180 OLYMPIC DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3393
Mailing Address - Country:US
Mailing Address - Phone:951-278-5590
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:31368 FLYING CLOUD DR
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2717
Practice Address - Country:US
Practice Address - Phone:949-464-9263
Practice Address - Fax:951-272-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR0208X
CA45265261QR0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0207XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile Mammography
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45265OtherDEPT OF HEALTH SERVICES
CA130682OtherFDA
CA130682OtherFDA