Provider Demographics
NPI:1285692970
Name:SIMI VALLEY MEDICAL IMAGING, LLC
Entity type:Organization
Organization Name:SIMI VALLEY MEDICAL IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO & EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:V
Authorized Official - Last Name:DIMARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-637-2991
Mailing Address - Street 1:PO BOX 94293
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6593
Mailing Address - Country:US
Mailing Address - Phone:425-637-2991
Mailing Address - Fax:425-637-4646
Practice Address - Street 1:1687 ERRINGER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6508
Practice Address - Country:US
Practice Address - Phone:805-527-4674
Practice Address - Fax:805-527-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056261Medicaid
CAGR0056261Medicaid