MEDICARE: SPINE AND SPORTS IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician		CA

General Provider Information

NPI Number	:	1295124352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND SPORTS IMAGING LLC

Provider Business Mailing Address
First Line	:	1120 W. LA VETA AVENUE
Second Line	:	SUITE 300
City	:	ORANGE
State	:	CA
Zip	:	92868-4233
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 W. LA VETA AVENUE
Second Line	:	SUITE 300
City	:	ORANGE
State	:	CA
Zip	:	92868-4233
Country	:	US
Telephone Number	:	949-280-2561
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. SCOTT LILLY
Credential	:
Telephone Number	:	805-701-8580

Provider Enumeration Date	:	01/13/2015
Last Update Date	:	01/13/2015

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