Basic Information
| Provider Information | |||||||||
| NPI: | 1144897778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COUNTY DIAGNOSTIC SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 617 | ||||||||
| Address2: | |||||||||
| City: | SOMERTON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853500617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283157910 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 S OAK AVE STE 7 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853360756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283665166 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2021 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | AGUIRRE | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9283157910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH COUNTY DIAGNOSTIC SERVICES, LLC | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.