MEDICARE: WASATCH MOBILE IMAGING, 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	:	1942978861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASATCH MOBILE IMAGING, LLC

Provider Business Mailing Address
First Line	:	90 W 500 S # 338
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-6230
Country	:	US
Telephone Number	:	801-897-5293
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 W 1950 S
Second Line	:
City	:	WOODS CROSS
State	:	UT
Zip	:	84087-5034
Country	:	US
Telephone Number	:	801-897-5293
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. KATHRINA GRAN
Credential	:	RN
Telephone Number	:	801-897-5293

Provider Enumeration Date	:	09/03/2021
Last Update Date	:	09/03/2021

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