MEDICARE: PACIFIC DIAGNOSTIC MEDICAL 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	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1548234776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC DIAGNOSTIC MEDICAL LLC

Provider Business Mailing Address
First Line	:	9454 CORDERO AVE
Second Line	:
City	:	TUJUNGA
State	:	CA
Zip	:	91042-3302
Country	:	US
Telephone Number	:	818-353-1774
Fax Number	:

Provider Business Practice Location Address
First Line	:	9454 CORDERO AVE
Second Line	:
City	:	TUJUNGA
State	:	CA
Zip	:	91042-3302
Country	:	US
Telephone Number	:	818-353-1774
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DWAYE KEVIN POWELL
Credential	:
Telephone Number	:	818-353-1774

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/22/2020

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