MEDICARE: WALNUT CREEK HEARTSCAN, 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	:	1750317269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALNUT CREEK HEARTSCAN, LLC

Provider Business Mailing Address
First Line	:	2161 YGNACIO VALLEY RD
Second Line	:	STE 100
City	:	WALNUT CREEK
State	:	CA
Zip	:	94598-3396
Country	:	US
Telephone Number	:	925-939-3003
Fax Number	:	925-939-3036

Provider Business Practice Location Address
First Line	:	2161 YGNACIO VALLEY RD
Second Line	:	STE 100
City	:	WALNUT CREEK
State	:	CA
Zip	:	94598-3396
Country	:	US
Telephone Number	:	925-939-3003
Fax Number	:	925-939-3036

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. ROBERT TYLER WOOLLEY
Credential	:
Telephone Number	:	916-591-0350

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	08/22/2020

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