Basic Information
| Provider Information | |||||||||
| NPI: | 1285692970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIMI VALLEY MEDICAL IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94293 | ||||||||
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| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981246593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256372991 | ||||||||
| FaxNumber: | 4256374646 | ||||||||
| Practice Location | |||||||||
| Address1: | 1687 ERRINGER RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930656508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055274674 | ||||||||
| FaxNumber: | 8055274675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | DIMARTINO | ||||||||
| AuthorizedOfficialFirstName: | NICK | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO & EXECUTIVE VP | ||||||||
| AuthorizedOfficialTelephone: | 4256372991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0056261 | 05 | CA | MEDICAID |