1609814102 NPI number — DEL AMO PET IMAGING CENTER LLC

Table of content: (NPI 1609814102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609814102 NPI number — DEL AMO PET IMAGING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEL AMO PET IMAGING CENTER 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:
1609814102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 BAYVIEW CIR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-2983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-544-3215
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3531 FASHION WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90503-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-316-2424
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MUELKEN
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC VP & CFO
Authorized Official Telephone Number:
800-544-3215

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  4834-19 , 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: EXE70140F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00189215 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ09162Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".