Provider Demographics
NPI:1013961630
Name:ADVANCED CARDIAC IMAGING CORPORATION
Entity Type:Organization
Organization Name:ADVANCED CARDIAC IMAGING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:SEVILLENO
Authorized Official - Last Name:BODOTA
Authorized Official - Suffix:
Authorized Official - Credentials:ARMDS
Authorized Official - Phone:562-401-0189
Mailing Address - Street 1:12632 BELLFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-4812
Mailing Address - Country:US
Mailing Address - Phone:562-401-0189
Mailing Address - Fax:562-401-0160
Practice Address - Street 1:12632 BELLFLOWER BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-4812
Practice Address - Country:US
Practice Address - Phone:562-401-0189
Practice Address - Fax:562-401-0160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIDTF00390Medicaid
CATG214Medicare ID - Type UnspecifiedIDTF
CAIDTF00390Medicaid