Provider Demographics
NPI:1083920607
Name:SOUTHERN CALIFORNIA MEDICAL DIAGNOSTICS GROUP, INC.
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA MEDICAL DIAGNOSTICS GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIM
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-995-5400
Mailing Address - Street 1:PO BOX 10094
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-3094
Mailing Address - Country:US
Mailing Address - Phone:818-244-4646
Mailing Address - Fax:818-244-2047
Practice Address - Street 1:1109 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2212
Practice Address - Country:US
Practice Address - Phone:213-484-0004
Practice Address - Fax:213-484-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43636A261QR0200X, 261QS1200X
CA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)