Provider Demographics
NPI:1548594278
Name:WEST COAST PETCT
Entity Type:Organization
Organization Name:WEST COAST PETCT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-835-6055
Mailing Address - Street 1:16300 SAND CANYON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3711
Mailing Address - Country:US
Mailing Address - Phone:714-835-6055
Mailing Address - Fax:
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:714-835-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST COAST RADIOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology