MEDICARE: CHARITY SIASOCO RT (R) (M)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471C3402X	Radiography Radiologic Technologist	311095	MI
2	2471M2300X	Mammography Radiologic Technologist	311095	MI

General Provider Information

NPI Number	:	1134413768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARITY SIASOCO RT (R) (M)

Provider Business Mailing Address
First Line	:	438 ORANGE AVE
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-1847
Country	:	US
Telephone Number	:	619-252-3653
Fax Number	:

Provider Business Practice Location Address
First Line	:	438 ORANGE AVE
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-1847
Country	:	US
Telephone Number	:	619-252-3653
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	05/31/2011

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Directions to “ CHARITY SIASOCO RT (R) (M)” Practice Location

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