MEDICARE: PORTABLE IMAGING OF NEVADA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1144583543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTABLE IMAGING OF NEVADA LLC

Provider Business Mailing Address
First Line	:	3675 PECOS MCLEOD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3815
Country	:	US
Telephone Number	:	702-836-9232
Fax Number	:	702-836-9555

Provider Business Practice Location Address
First Line	:	3675 PECOS MCLEOD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3815
Country	:	US
Telephone Number	:	702-836-9232
Fax Number	:	702-836-9555

Authorized Official
Title or Position	:	MANAGING MEMBE
Name	:	MR. JONATHAN R MONKS
Credential	:
Telephone Number	:	702-525-1778

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	06/20/2012

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