Healthcare Provider Details

I. General information

NPI: 1902858384
Provider Name (Legal Business Name): SOUTH COAST RADIOLOGICAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24451 HEALTH CENTER DRIVE
LAGUNA HILLS CA
92653-3689
US

IV. Provider business mailing address

5110 E. CLINTON WAY
FRESNO CA
93727-2040
US

V. Phone/Fax

Practice location:
  • Phone: 949-452-3573
  • Fax: 949-352-3573
Mailing address:
  • Phone: 559-455-4065
  • Fax: 770-666-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD JONATHAN WASLEY
Title or Position: CEO/PRESIDENT
Credential: M.D.
Phone: 949-452-3573