Provider Demographics
NPI:1598063133
Name:SOURCE DIAGNOSTICS WEST LLC
Entity Type:Organization
Organization Name:SOURCE DIAGNOSTICS WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEZACAPA
Authorized Official - Suffix:
Authorized Official - Credentials:RT (R) MR, CT
Authorized Official - Phone:760-777-4352
Mailing Address - Street 1:49440 VIA POMPA
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253
Mailing Address - Country:US
Mailing Address - Phone:760-777-4352
Mailing Address - Fax:
Practice Address - Street 1:49440 VIA POMPA
Practice Address - Street 2:
Practice Address - City:LQ
Practice Address - State:CA
Practice Address - Zip Code:92253
Practice Address - Country:US
Practice Address - Phone:760-777-4352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246XS1301X, 2471S1302X, 2471V0105X
CA00080313335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Single Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty