Basic Information
| Provider Information | |||||||||
| NPI: | 1922677004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COUNTY DIAGNOSTIC SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 617 | ||||||||
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| City: | SOMERTON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283157910 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 S. OAK AVENUE | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | SAN LUIS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283665166 | ||||||||
| FaxNumber: | 9287226113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2021 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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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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| AuthorizedOfficialCredential: | R.D. | ||||||||
| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.