Provider Demographics
NPI:1649207812
Name:SAN DIEGO IMAGING-CHULA VISTA LLC
Entity type:Organization
Organization Name:SAN DIEGO IMAGING-CHULA VISTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PADELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-565-0950
Mailing Address - Street 1:PO BOX 939054
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-9054
Mailing Address - Country:US
Mailing Address - Phone:858-565-0950
Mailing Address - Fax:858-244-1100
Practice Address - Street 1:765 MEDICAL CENTER COURT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:619-397-6577
Practice Address - Fax:619-502-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA04414006261QM1200X, 261QR0206X, 261QR0200X
CA05138506261QM1200X
CA05158506261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083811Medicaid
CAGR0083811Medicaid
CACB246718Medicare PIN