Basic Information
| Provider Information | |||||||||
| NPI: | 1649207812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO IMAGING-CHULA VISTA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939054 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921939054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585650950 | ||||||||
| FaxNumber: | 8582441100 | ||||||||
| Practice Location | |||||||||
| Address1: | 765 MEDICAL CENTER COURT | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193976577 | ||||||||
| FaxNumber: | 6195028585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 12/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | PADELFORD | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8585650950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | 04414006 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QM1200X | 05138506 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0200X | 05158506 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | 04414006 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | 04414006 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0083811 | 05 | CA | MEDICAID |