Provider Demographics
NPI:1780639765
Name:BREA DIAGNOSTIC CARDIAC IMAGING
Entity Type:Organization
Organization Name:BREA DIAGNOSTIC CARDIAC IMAGING
Other - Org Name:BREA DOAGNOSTIC CARDIAC IMAGING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA LUISA
Authorized Official - Middle Name:TINSAY
Authorized Official - Last Name:LOCSIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-257-0246
Mailing Address - Street 1:P.O. BOX 8747
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-5747
Mailing Address - Country:US
Mailing Address - Phone:714-257-0245
Mailing Address - Fax:714-257-9120
Practice Address - Street 1:379 W. CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3041
Practice Address - Country:US
Practice Address - Phone:714-257-0246
Practice Address - Fax:714-257-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7435-30261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY42199Medicare UPIN
Y42199Medicare UPIN
TP128Medicare PIN