MEDICARE: UPSCALE ULTRASOUND & MOBILE 3D 4D, 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	261QR0200X	Radiology Clinic/Center	134780	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1871951244	OTHER	FL	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1942751110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPSCALE ULTRASOUND & MOBILE 3D 4D, LLC

Provider Business Mailing Address
First Line	:	145 HILDEN RD
Second Line	:	STE 113
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-8401
Country	:	US
Telephone Number	:	904-465-9062
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 HILDEN RD
Second Line	:	STE 113
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-8401
Country	:	US
Telephone Number	:	904-465-9062
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEAH R CARROLL
Credential	:	RDMS
Telephone Number	:	904-465-9062

Provider Enumeration Date	:	10/21/2016
Last Update Date	:	10/21/2016

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