Basic Information
| Provider Information | |||||||||
| NPI: | 1255440194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBOR-UCLA DIAGNOSTIC IMAGING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21840 NORMANDIE AVE | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905022047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102225015 | ||||||||
| FaxNumber: | 3102225027 | ||||||||
| Practice Location | |||||||||
| Address1: | 21828 NORMANDIE AVE | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905022047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102222801 | ||||||||
| FaxNumber: | 3103284919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3102225015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0009901 | 05 | CA | MEDICAID |