Organization
SOURCE DIAGNOSTICS WEST LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PAUL J MEZACAPA RT. (R) MR, CT (MANAGING MEMBER)
(760) 777-4352
Entity
Organization
Contact information
Practice address
49440 VIA POMPA, LQ, CA 92253
(760) 777-4352
Mailing address
49440 VIA POMPA, LA QUINTA, CA 92253
(760) 777-4352
Taxonomy
Speciality
Code
Description
License number
State
246XS1301X
Sonography Specialist/Technologist Cardiovascular
—
—
2471S1302X
Sonography Radiologic Technologist
—
—
2471V0105X
Vascular Sonography Radiologic Technologist
—
—
335V00000X
Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
Primary
00080313
CA
Other
Enumeration date
03/07/2011
Last updated
05/18/2011
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