Healthcare Provider Details

I. General information

NPI: 1275721540
Provider Name (Legal Business Name): LISA ANNE SEDILLO ARRT R M, RDMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W 6TH ST
SAN PEDRO CA
90732-3514
US

IV. Provider business mailing address

1367 W 20TH ST
SAN PEDRO CA
90732-4407
US

V. Phone/Fax

Practice location:
  • Phone: 310-514-5243
  • Fax:
Mailing address:
  • Phone: 310-832-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number155559
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number41845
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number17109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: