Healthcare Provider Details

I. General information

NPI: 1720730633
Provider Name (Legal Business Name): SOUTH BAY X-RAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 S HARLAN AVE
COMPTON CA
90220-4215
US

IV. Provider business mailing address

1029 S HARLAN AVE
COMPTON CA
90220-4215
US

V. Phone/Fax

Practice location:
  • Phone: 310-989-1677
  • Fax:
Mailing address:
  • Phone: 310-989-1677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSE A VASCONEZ
Title or Position: OWNER
Credential: R.T (R)
Phone: 310-989-1677