=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346652781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRACTICE DIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2014
-----------------------------------------------------
Last Update Date | 05/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 N TUSTIN AVE SUITE 120
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-340-5990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 921332
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91392-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-356-0661
-----------------------------------------------------
Fax | 818-364-1751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. SHAWN M ROWLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-356-0661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------