Healthcare Provider Details

I. General information

NPI: 1073817490
Provider Name (Legal Business Name): SCAN HEALTH IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13943 N 91ST AVE SUITE 102
PEORIA AZ
85381-3629
US

IV. Provider business mailing address

13943 N 91ST AVE SUITE 102
PEORIA AZ
85381-3629
US

V. Phone/Fax

Practice location:
  • Phone: 623-815-8200
  • Fax: 623-344-5458
Mailing address:
  • Phone: 623-815-8200
  • Fax: 623-344-5458

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28033
License Number StateAZ

VIII. Authorized Official

Name: DR. MANNTEJ SRA
Title or Position: OWNER
Credential: M.D
Phone: 623-815-8200