Provider Demographics
NPI:1003088832
Name:SOLMAZ MODEER
Entity Type:Organization
Organization Name:SOLMAZ MODEER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOLMAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MODEER
Authorized Official - Suffix:
Authorized Official - Credentials:RT, RTM
Authorized Official - Phone:619-409-6939
Mailing Address - Street 1:14795 CAMINITO ORENSE ESTE
Mailing Address - Street 2:SAN DIEGO
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-1532
Mailing Address - Country:US
Mailing Address - Phone:619-409-6939
Mailing Address - Fax:619-409-6949
Practice Address - Street 1:1635 3RD AVE STE G
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-5884
Practice Address - Country:US
Practice Address - Phone:619-409-6939
Practice Address - Fax:619-409-6949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN DIAGNOSTIC IMAGING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-01
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATG145291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIDTF00430Medicaid
CAIDTF00430Medicaid