=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609814102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEL AMO PET IMAGING CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2006
-----------------------------------------------------
Last Update Date | 09/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3531 FASHION WAY
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90503-4807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-316-2424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 BAYVIEW CIR SUITE 400
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-544-3215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC VP & CFO
-----------------------------------------------------
Name | STEVE MUELKEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-544-3215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | 4834-19
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------