Provider Demographics
NPI:1417146903
Name:SD XRAY LLC
Entity Type:Organization
Organization Name:SD XRAY LLC
Other - Org Name:SDXRAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-274-8807
Mailing Address - Street 1:P.O. BOX 4554
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765
Mailing Address - Country:US
Mailing Address - Phone:619-466-5628
Mailing Address - Fax:619-697-0153
Practice Address - Street 1:8900 GROSSMONT BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-4047
Practice Address - Country:US
Practice Address - Phone:619-466-5628
Practice Address - Fax:909-595-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR0510003BMedicare PIN