Provider Demographics
NPI:1104879121
Name:SAN DIEGO REGIONAL P.E.T. CENTER, LLC
Entity type:Organization
Organization Name:SAN DIEGO REGIONAL P.E.T. CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-499-0230
Mailing Address - Street 1:PO BOX 910026
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7625 MESA COLLEGE DR
Practice Address - Street 2:102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5343
Practice Address - Country:US
Practice Address - Phone:858-499-0230
Practice Address - Fax:858-499-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ08027OtherBLUE SHIELD
TG148Medicare ID - Type Unspecified