Healthcare Provider Details

I. General information

NPI: 1730425547
Provider Name (Legal Business Name): PORTABLE MEDICAL DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9047 HOME AVE
IRVINGTON AL
36544-2855
US

IV. Provider business mailing address

1855 LAKELAND DR STE G10
JACKSON MS
39216-4913
US

V. Phone/Fax

Practice location:
  • Phone: 251-272-1080
  • Fax: 251-272-1080
Mailing address:
  • Phone: 601-987-9729
  • Fax: 601-987-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS BROWN
Title or Position: MANAGING MEMBER
Credential:
Phone: 601-987-9729