1174804355 NPI number — PORTABLE MEDICAL DIAGNOSTICS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174804355 NPI number — PORTABLE MEDICAL DIAGNOSTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTABLE MEDICAL DIAGNOSTICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174804355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1855 LAKELAND DR
Provider Second Line Business Mailing Address:
STE G10
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-987-9729
Provider Business Mailing Address Fax Number:
601-987-0093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1855 LAKELAND DR
Provider Second Line Business Practice Location Address:
STE G10
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-987-9729
Provider Business Practice Location Address Fax Number:
601-987-0093
Provider Enumeration Date:
09/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
601-260-6008

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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