Basic Information
| Provider Information | |||||||||
| NPI: | 1942457130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO CARDIOVASCULAR IMAGING SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 754 MEDICAL CENTER CT | ||||||||
| Address2: | #204 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919116654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196162100 | ||||||||
| FaxNumber: | 6196162104 | ||||||||
| Practice Location | |||||||||
| Address1: | 754 MEDICAL CENTER CT | ||||||||
| Address2: | #204 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919116654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196162100 | ||||||||
| FaxNumber: | 6196162104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | MOUSSAVIAN | ||||||||
| AuthorizedOfficialFirstName: | MEHRAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6196162100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246X00000X | 20A7241 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Cardiovascular |
No ID Information.