MEDICARE: EAST COAST DIAGNOSTICS 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	:	1205231107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST COAST DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	2840 PINE RD
Second Line	:	SUITE D1
City	:	HUNTINGDON VALLEY
State	:	PA
Zip	:	19006-4258
Country	:	US
Telephone Number	:	215-967-1079
Fax Number	:

Provider Business Practice Location Address
First Line	:	2021 MARTIN LUTHER KING JR AVE SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-7007
Country	:	US
Telephone Number	:	215-967-1079
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LOUISA KIPERVAS
Credential	:
Telephone Number	:	215-967-1079

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	11/04/2014

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