Provider Demographics
NPI:1891232294
Name:BACK BAY IMAGING INC.
Entity Type:Organization
Organization Name:BACK BAY IMAGING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETZOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-736-4395
Mailing Address - Street 1:4640 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6621
Mailing Address - Country:US
Mailing Address - Phone:310-736-4395
Mailing Address - Fax:
Practice Address - Street 1:301 BAYVIEW CIR
Practice Address - Street 2:SUITE 105
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2948
Practice Address - Country:US
Practice Address - Phone:310-736-4395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology