Provider Demographics
NPI:1427593805
Name:WESTERN IMAGING MARINA DEL REY INC
Entity Type:Organization
Organization Name:WESTERN IMAGING MARINA DEL REY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:PETZOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-736-4395
Mailing Address - Street 1:4640 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6621
Mailing Address - Country:US
Mailing Address - Phone:310-736-4395
Mailing Address - Fax:
Practice Address - Street 1:4640 ADMIRALTY WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6621
Practice Address - Country:US
Practice Address - Phone:310-736-4395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology