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General NPI Number Information
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NPI Number | 1700907433
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Entity Type | Organization
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Legal Business Name | MEDICAL IMAGING CENTER OF SOUTHERN CALIFORNIA
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2827 WILSHIRE BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90403-4801
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Country | US
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Telephone | 310-829-9788
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Fax | 310-453-1576
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Provider Business Mailing Address
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Address Line | 2827 WILSHIRE BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90403-4801
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Country | US
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Telephone | 310-829-9788
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Fax | 310-453-1576
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | DAIRZETTE LAYNE
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Credential |
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Telephone | 310-829-9788
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | W13479
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License Number State | CA
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