Provider Demographics
NPI:1548225089
Name:ST JOHNS REGIONAL IMAGING CENTER LLC
Entity Type:Organization
Organization Name:ST JOHNS REGIONAL IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR V.P. & CHIEF ACCOUNTING OFCR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DRAZBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-282-6000
Mailing Address - Street 1:PO BOX 844350
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-4350
Mailing Address - Country:US
Mailing Address - Phone:888-685-3914
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:STE 110
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3790
Practice Address - Country:US
Practice Address - Phone:805-983-0883
Practice Address - Fax:805-983-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA470000913OtherRAILROAD MEDICARE
CADIAA00370Medicaid
CATP044Medicare PIN