Healthcare Provider Details

I. General information

NPI: 1154565802
Provider Name (Legal Business Name): SOUTHEAST X-RAY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22601 N 19TH AVE STE 108
PHOENIX AZ
85027-1324
US

IV. Provider business mailing address

22601 N 19TH AVE STE 108
PHOENIX AZ
85027-1324
US

V. Phone/Fax

Practice location:
  • Phone: 480-369-1270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT SCOTT THORNOCK
Title or Position: CHIEF STRATEGY OFFICER
Credential:
Phone: 480-369-1270