MEDICARE: KECK MEDICINE OF USC IMAGING CENTERS, LLC

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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1669292405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KECK MEDICINE OF USC IMAGING CENTERS, LLC

Provider Business Mailing Address
First Line	:	1510 SAN PABLO ST STE 600
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-5405
Country	:	US
Telephone Number	:	323-442-8747
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 S FAIR OAKS AVE STE 143
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-2614
Country	:	US
Telephone Number	:	626-517-8676
Fax Number	:	626-517-8677

Authorized Official
Title or Position	:	CFO
Name	:	JEREMY CHURCH
Credential	:
Telephone Number	:	323-442-8747

Provider Enumeration Date	:	10/16/2024
Last Update Date	:	12/29/2025

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