=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780639765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREA DIAGNOSTIC CARDIAC IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 05/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 379 W. CENTRAL AVE.
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92821-3041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-257-0246
-----------------------------------------------------
Fax | 714-257-9120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 8747
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92822-5747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-257-0245
-----------------------------------------------------
Fax | 714-257-9120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | MS. MARIA LUISA TINSAY LOCSIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-257-0246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | 7435-30
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------