1336234772 NPI number — PORTABLE X RAY OF ARIZONA LLC

Table of content: (NPI 1336234772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336234772 NPI number — PORTABLE X RAY OF ARIZONA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTABLE X RAY OF ARIZONA 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:
1336234772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5538 WEST DUNCAN DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-395-5011
Provider Business Mailing Address Fax Number:
702-645-2874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2338 WEST ROYAL PALM DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-864-3656
Provider Business Practice Location Address Fax Number:
602-864-3660
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROSSA
Authorized Official First Name:
ABBY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
702-395-5011

Provider Taxonomy Codes

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

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

  • Identifier: 2Z1598 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 579055 . This is a "HEALTHCHOICE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 579055 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AW2888 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0890990 . This is a "BULE CROSS BLUE SHIELD OF" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 579055 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65945 . This is a "SCAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: F10081 . This is a "PHOENIX HEALTH PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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