Healthcare Provider Details

I. General information

NPI: 1184745820
Provider Name (Legal Business Name): HEAD AND NECK IMAGING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2827 WILSHIRE BLVD
SANTA MONICA CA
90403-4801
US

IV. Provider business mailing address

2827 WILSHIRE BLVD
SANTA MONICA CA
90403-4801
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-9788
  • Fax: 310-453-1576
Mailing address:
  • Phone: 310-829-9788
  • Fax: 310-453-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberW11873
License Number StateCA

VIII. Authorized Official

Name: DAIRZETTE LAYNE
Title or Position: BILLING MANAGER
Credential:
Phone: 310-829-9788