Provider Demographics
NPI:1164885992
Name:PMDTC, LLC
Entity Type:Organization
Organization Name:PMDTC, LLC
Other - Org Name:TOWN AND COUNTRY DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:1600 W BROADWAY RD STE 155
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1138
Mailing Address - Country:US
Mailing Address - Phone:801-529-8638
Mailing Address - Fax:
Practice Address - Street 1:30 HUGHES STE 208
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-1916
Practice Address - Country:US
Practice Address - Phone:602-249-4790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB261664Medicare Oscar/Certification
CACA209371Medicare Oscar/Certification
CAW0032OtherSOUTHERN MEDICARE PROVIDER ID
CACA209371Medicare Oscar/Certification