Organization
MEDICAL IMAGING CENTER OF SOUTHERN CALIFORNIA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAIRZETTE LAYNE (BILLING MANAGER)
(310) 829-9788
Entity
Organization
Contact information
Practice address
2827 WILSHIRE BLVD, SANTA MONICA, CA 90403-4801
(310) 829-9788
(310) 453-1576
Mailing address
2827 WILSHIRE BLVD, SANTA MONICA, CA 90403-4801
(310) 829-9788
(310) 453-1576
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
W13479
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
123448
MAMMOGRAPHY CERTIFICATION
CA
01
—
ZZZ15575Z
BLUE SHIELD OF CA
CA
Enumeration date
04/02/2007
Last updated
08/22/2020
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