Provider Demographics
NPI:1437108776
Name:MOLECULAR IMAGING SORRENTO VALLEY, LLC
Entity Type:Organization
Organization Name:MOLECULAR IMAGING SORRENTO VALLEY, LLC
Other - Org Name:UCSD CENTER FOR MOLECULAR IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-642-0032
Mailing Address - Street 1:9530 TOWNE CENTRE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1981
Mailing Address - Country:US
Mailing Address - Phone:858-642-0032
Mailing Address - Fax:858-642-0052
Practice Address - Street 1:11388 SORRENTO VALLEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1345
Practice Address - Country:US
Practice Address - Phone:858-373-2860
Practice Address - Fax:858-373-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB2003020474261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG302Medicare ID - Type UnspecifiedSORRENTO VALLEY LLC