Healthcare Provider Details

I. General information

NPI: 1740429422
Provider Name (Legal Business Name): WEST COAST RADIOLOGY CENTER SOUTH COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 S BRISTOL ST
SANTA ANA CA
92704-5727
US

IV. Provider business mailing address

PO BOX 11924
SANTA ANA CA
92711-1924
US

V. Phone/Fax

Practice location:
  • Phone: 714-966-0904
  • Fax: 714-966-0972
Mailing address:
  • Phone: 714-835-3709
  • Fax: 714-836-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL L. BLACK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 714-835-6055