Healthcare Provider Details

I. General information

NPI: 1578566808
Provider Name (Legal Business Name): GCC IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 AERICK ST # 105
INGLEWOOD CA
90301-1978
US

IV. Provider business mailing address

633 AERICK ST # 105
INGLEWOOD CA
90301-1978
US

V. Phone/Fax

Practice location:
  • Phone: 310-412-8181
  • Fax: 310-412-9299
Mailing address:
  • Phone: 310-412-8181
  • Fax: 310-412-9299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number7280-19
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF336330
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number7280-19
License Number StateCA

VIII. Authorized Official

Name: MR. MO SOULATI
Title or Position: BILLING MANAGER
Credential:
Phone: 310-412-8181