Healthcare Provider Details

I. General information

NPI: 1669292405
Provider Name (Legal Business Name): KECK MEDICINE OF USC IMAGING CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S FAIR OAKS AVE STE 143
PASADENA CA
91105-2614
US

IV. Provider business mailing address

1510 SAN PABLO ST STE 600
LOS ANGELES CA
90033-5405
US

V. Phone/Fax

Practice location:
  • Phone: 626-517-8676
  • Fax: 626-517-8677
Mailing address:
  • Phone: 323-442-8747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY CHURCH
Title or Position: CFO
Credential:
Phone: 323-442-8747