MEDICARE: CT. MOBILE DIAGNOSTIC SERVICES

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	335V00000X	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier

General Provider Information

NPI Number	:	1922126051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CT. MOBILE DIAGNOSTIC SERVICES

Provider Business Mailing Address
First Line	:	249 W MAIN ST
Second Line	:	C-3
City	:	BRANFORD
State	:	CT
Zip	:	06405-4048
Country	:	US
Telephone Number	:	203-488-1718
Fax Number	:	203-488-5016

Provider Business Practice Location Address
First Line	:	249 W MAIN ST
Second Line	:	C-3
City	:	BRANFORD
State	:	CT
Zip	:	06405-4048
Country	:	US
Telephone Number	:	203-488-1718
Fax Number	:	203-488-5016

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARK GAMBARDELLA
Credential	:
Telephone Number	:	203-488-1718

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	08/22/2020

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