Provider Demographics
NPI:1801036751
Name:LIFESCAPE IMAGING CYPRESS LLC
Entity Type:Organization
Organization Name:LIFESCAPE IMAGING CYPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROTONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-265-3123
Mailing Address - Street 1:10601 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4733
Mailing Address - Country:US
Mailing Address - Phone:714-656-2130
Mailing Address - Fax:
Practice Address - Street 1:24584 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6807
Practice Address - Country:US
Practice Address - Phone:310-783-7656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29726174400000X
CAG065833174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty