1588695217 NPI number — SAN DIEGO IMAGING - CHULA VISTA, LLC

Table of content: (NPI 1588695217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588695217 NPI number — SAN DIEGO IMAGING - CHULA VISTA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN DIEGO IMAGING - CHULA VISTA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588695217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 939054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92193-9054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-565-0950
Provider Business Mailing Address Fax Number:
858-244-1100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 KUHN DR STE 100
Provider Second Line Business Practice Location Address:
SAN DIEGO IMAGING - EASTLAKE
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914-4517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-397-6577
Provider Business Practice Location Address Fax Number:
619-397-5182
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PADELFORD
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
858-565-0950

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  044140-06 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X , with the licence number: 044140-06 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0083815 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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