Provider Demographics
NPI:1184745820
Name:HEAD AND NECK IMAGING ASSOCIATES
Entity type:Organization
Organization Name:HEAD AND NECK IMAGING ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAIRZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-829-9788
Mailing Address - Street 1:2827 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4801
Mailing Address - Country:US
Mailing Address - Phone:310-829-9788
Mailing Address - Fax:310-453-1576
Practice Address - Street 1:2827 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4801
Practice Address - Country:US
Practice Address - Phone:310-829-9788
Practice Address - Fax:310-453-1576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW118732085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ496712OtherBLUE SHIELD OF CA
CAGR0071050Medicaid
CAZZZ496712OtherBLUE SHIELD OF CA
CAGR0071050Medicaid