Healthcare Provider Details

I. General information

NPI: 1255601613
Provider Name (Legal Business Name): HIGH DESERT RADIOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 SOUTHERN VISTA DR
KINGMAN AZ
86401-0630
US

IV. Provider business mailing address

P.O. BOX 4148
KINGMAN AZ
86402-4148
US

V. Phone/Fax

Practice location:
  • Phone: 928-718-0180
  • Fax: 928-718-0181
Mailing address:
  • Phone: 928-718-0180
  • Fax: 928-718-0181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number42974
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number42974
License Number StateAZ

VIII. Authorized Official

Name: KALE D BODILY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 928-757-0620