Provider Demographics
NPI:1265466189
Name:LITTLE COMPANY OF MARY ANCILLARY SERVICES CORPORATION
Entity Type:Organization
Organization Name:LITTLE COMPANY OF MARY ANCILLARY SERVICES CORPORATION
Other - Org Name:PLCM OUTPATIENT IMAGING TORRANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR-REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 2333
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2333
Mailing Address - Country:US
Mailing Address - Phone:310-316-2424
Mailing Address - Fax:310-540-0374
Practice Address - Street 1:5215 TORRANCE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4009
Practice Address - Country:US
Practice Address - Phone:310-316-2424
Practice Address - Fax:310-540-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARGR0023350Medicaid
CAW13537OtherBLUE CROSS PROV#
CAZZZ10758ZOtherBLUE SHIELD PROV#
CAW13537Medicare Oscar/Certification