Provider Demographics
NPI:1245455773
Name:SOUTHERN CALIFORNIA DIAGNOSTIC IMAGING, INC.
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA DIAGNOSTIC IMAGING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-995-5471
Mailing Address - Street 1:408 S. BEACH BLVD.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1873
Mailing Address - Country:US
Mailing Address - Phone:714-995-5471
Mailing Address - Fax:714-995-5815
Practice Address - Street 1:408 S. BEACH BLVD.
Practice Address - Street 2:SUITE 106
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1873
Practice Address - Country:US
Practice Address - Phone:714-995-5471
Practice Address - Fax:714-995-5815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0202X
CA24687261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0964335Medicaid
CA0964335Medicaid
CAW18918Medicare ID - Type Unspecified
W18918Medicare PIN