Healthcare Provider Details

I. General information

NPI: 1407200546
Provider Name (Legal Business Name): SOCAL DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S ANAHEIM BLVD SUITE 160
ANAHEIM CA
92805-6242
US

IV. Provider business mailing address

1500 S ANAHEIM BLVD SUITE 160
ANAHEIM CA
92805-6242
US

V. Phone/Fax

Practice location:
  • Phone: 657-999-5679
  • Fax:
Mailing address:
  • Phone: 657-999-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON AARON WALTER DAVID
Title or Position: MEMBER
Credential:
Phone: 657-999-5679