MEDICARE: LOS ALAMITOS RADIOLOGY GROUP INC

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

General Provider Information

NPI Number	:	1861975203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOS ALAMITOS RADIOLOGY GROUP INC

Provider Business Mailing Address
First Line	:	PO BOX 650
Second Line	:
City	:	NEWBURY PARK
State	:	CA
Zip	:	91319-0650
Country	:	US
Telephone Number	:	805-375-8804
Fax Number	:	770-237-1429

Provider Business Practice Location Address
First Line	:	36589 SCULPTURE POINT DRIVE
Second Line	:
City	:	THE SEA RANCH
State	:	CA
Zip	:	95497-0000
Country	:	US
Telephone Number	:	323-876-8207
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. VINCENT S. POLEK
Credential	:
Telephone Number	:	805-375-8804

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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