Healthcare Provider Details

I. General information

NPI: 1104991124
Provider Name (Legal Business Name): VALLEY DIAGNOSTICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 W MAIN ST STE H
RUSSELLVILLE AR
72801-2533
US

IV. Provider business mailing address

PO BOX 9010
RUSSELLVILLE AR
72811-9010
US

V. Phone/Fax

Practice location:
  • Phone: 479-967-6492
  • Fax: 479-967-6509
Mailing address:
  • Phone: 479-967-6492
  • Fax: 479-967-6509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. MONTI L KIST
Title or Position: OWNER
Credential:
Phone: 479-967-6492