Provider Demographics
NPI:1164471157
Name:REVEAL DIAGNOSTIC IMAGING OF CALIFORNIA LLC
Entity Type:Organization
Organization Name:REVEAL DIAGNOSTIC IMAGING OF CALIFORNIA LLC
Other - Org Name:DIAGNOSTIC HEALTH LOS ANGELES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PELKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-981-4848
Mailing Address - Street 1:22 INVERNESS CENTER PKWY
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4814
Mailing Address - Country:US
Mailing Address - Phone:205-981-4848
Mailing Address - Fax:205-994-7018
Practice Address - Street 1:6801 PARK TER
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-665-7180
Practice Address - Fax:310-665-7184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFQ818AMedicare PIN