1164434098 NPI number — EAST VALLEY DIAGNOSTIC IMAGING LLC

Table of content: (NPI 1164434098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164434098 NPI number — EAST VALLEY DIAGNOSTIC IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST VALLEY DIAGNOSTIC IMAGING 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:
6
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:
1164434098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 E. SOUTHERN AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85204-5046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-545-8119
Provider Business Mailing Address Fax Number:
480-926-8332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 E. SOUTHERN AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-5046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-545-8119
Provider Business Practice Location Address Fax Number:
480-926-8332
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARKS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
480-272-8004

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 585681 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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