Provider Demographics
NPI:1629021167
Name:DESERT PET IMAGING, LLC
Entity Type:Organization
Organization Name:DESERT PET IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-370-0200
Mailing Address - Street 1:250 N WESTLAKE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3700
Mailing Address - Country:US
Mailing Address - Phone:805-370-0200
Mailing Address - Fax:805-370-0205
Practice Address - Street 1:1180 N INDIAN CANYON DR
Practice Address - Street 2:ROOM E-155
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4800
Practice Address - Country:US
Practice Address - Phone:760-327-8000
Practice Address - Fax:760-327-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEXEMPT261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28648ZMedicare PIN