Provider Demographics
NPI:1861962185
Name:SO CAL IMAGING LLC
Entity type:Organization
Organization Name:SO CAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPPICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-241-0742
Mailing Address - Street 1:3835 RE THOUSAND OAKS BLVD., #385
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362
Mailing Address - Country:US
Mailing Address - Phone:818-312-4555
Mailing Address - Fax:800-915-0607
Practice Address - Street 1:2075 HATHAWAY AVE
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-5171
Practice Address - Country:US
Practice Address - Phone:818-312-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No251X00000XAgenciesSupports Brokerage