Provider Demographics
NPI:1700907433
Name:MEDICAL IMAGING CENTER OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:MEDICAL IMAGING CENTER OF SOUTHERN CALIFORNIA
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
CAW134792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA123448OtherMAMMOGRAPHY CERTIFICATION
CAZZZ15575ZOtherBLUE SHIELD OF CA
CAZZZ15575ZOtherBLUE SHIELD OF CA
CA123448OtherMAMMOGRAPHY CERTIFICATION