MEDICARE: MOBILE DIAGNOSTIC SERVICES, 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	171W00000X	Contractor

General Provider Information

NPI Number	:	1528305190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE DIAGNOSTIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	3714 SW 12TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-5115
Country	:	US
Telephone Number	:	239-220-0720
Fax Number	:	239-220-5525

Provider Business Practice Location Address
First Line	:	3714 SW 12TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-5115
Country	:	US
Telephone Number	:	239-220-0720
Fax Number	:	239-220-5525

Authorized Official
Title or Position	:	MANAGING/OWNER
Name	:	KATHLEEN MASTERSON
Credential	:
Telephone Number	:	239-220-0720

Provider Enumeration Date	:	01/15/2013
Last Update Date	:	01/25/2013

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Directions to “MOBILE DIAGNOSTIC SERVICES, LLC ” Practice Location

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