1780021857 NPI number — SOUTHERN CALIFORNIA MOBILE X-RAY, LLC.

Table of content: (NPI 1780021857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780021857 NPI number — SOUTHERN CALIFORNIA MOBILE X-RAY, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CALIFORNIA MOBILE X-RAY, 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:
6
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:
1780021857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31945 COAST HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-6867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-308-2453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31945 COAST HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-308-2453
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LIU
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
702-308-2453

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , with the licence number:  FAC72258 , 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: 72258 . This is a "CDPH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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