Healthcare Provider Details

I. General information

NPI: 1740204346
Provider Name (Legal Business Name): ENTERPRISE OPEN MRI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROFESSIONAL LANE SUITE B
ENTERPRISE AL
36330
US

IV. Provider business mailing address

194 E. REDSTONE AVE. SUITE A
CRESTVIEW FL
32539-5348
US

V. Phone/Fax

Practice location:
  • Phone: 334-308-1524
  • Fax: 334-308-1528
Mailing address:
  • Phone: 334-684-7156
  • Fax: 334-684-7709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN C. TOMBERLIN
Title or Position: OWNER
Credential: M.D.
Phone: 334-684-7156