1104923614 NPI number — DIAGNOSTIC MOBILE X-RAY INC

Table of content: (NPI 1104923614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104923614 NPI number — DIAGNOSTIC MOBILE X-RAY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAGNOSTIC MOBILE X-RAY INC
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:
1104923614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28100 CHALLENGER BLVD
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
PUNTA GORDA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-639-9729
Provider Business Mailing Address Fax Number:
941-639-5100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28100 CHALLENGER BLVD
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
PUNTA GORDA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-639-9729
Provider Business Practice Location Address Fax Number:
941-639-5100
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GATZ
Authorized Official First Name:
JONELL
Authorized Official Middle Name:
MELAINE
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
941-639-9729

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 510029100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com