Healthcare Provider Details

I. General information

NPI: 1043451230
Provider Name (Legal Business Name): WEST COAST PETCT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 SAND CANYON AVE SUITE 103
IRVINE CA
92618-3711
US

IV. Provider business mailing address

100 BAYVIEW CIR SUITE 400
NEWPORT BEACH CA
92660-2983
US

V. Phone/Fax

Practice location:
  • Phone: 866-533-4296
  • Fax:
Mailing address:
  • Phone: 949-242-5384
  • Fax: 480-212-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: NICHOLAS A. POAN
Title or Position: SVP - CORPORATE FINANCE
Credential:
Phone: 949-242-5321