1104879121 NPI number — SAN DIEGO REGIONAL P.E.T. CENTER, LLC

Table of content: (NPI 1104879121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104879121 NPI number — SAN DIEGO REGIONAL P.E.T. CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN DIEGO REGIONAL P.E.T. 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:
1104879121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 910026
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:
92191-0026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7625 MESA COLLEGE DR
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-5343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-499-0230
Provider Business Practice Location Address Fax Number:
858-499-0231
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLEARY
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
858-499-0230

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: ZZZ08027 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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