Healthcare Provider Details

I. General information

NPI: 1710369228
Provider Name (Legal Business Name): MOBILE DYSPHAGIA IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 CRESTWOOD ST
SPRINGDALE AR
72762-5119
US

IV. Provider business mailing address

806 CRESTWOOD ST
SPRINGDALE AR
72762-5119
US

V. Phone/Fax

Practice location:
  • Phone: 479-253-4430
  • Fax:
Mailing address:
  • Phone: 479-253-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License NumberRTL6981
License Number StateAR

VIII. Authorized Official

Name: TIMOTHY ERIC PAYNE
Title or Position: MEMBER
Credential: RT(R)
Phone: 479-253-4430