1073755419 NPI number — SOUTHWEST DIAGNOSTIC SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073755419 NPI number — SOUTHWEST DIAGNOSTIC SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST DIAGNOSTIC SERVICES, 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:
1073755419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 E 3RD ST
Provider Second Line Business Mailing Address:
P.O. BOX 31-411
Provider Business Mailing Address City Name:
CALEXICO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92231-2760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-460-4022
Provider Business Mailing Address Fax Number:
760-460-4371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 HEFFERNAN AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
CALEXICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92231-4718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-460-4022
Provider Business Practice Location Address Fax Number:
760-460-4371
Provider Enumeration Date:
03/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MENDOZA
Authorized Official First Name:
IVAN
Authorized Official Middle Name:
ARMANDO
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
760-562-7827

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com