Healthcare Provider Details

I. General information

NPI: 1336234772
Provider Name (Legal Business Name): PORTABLE X RAY OF ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2338 WEST ROYAL PALM DRIVE
PHOENIX AZ
85021
US

IV. Provider business mailing address

5538 WEST DUNCAN DRIVE
LAS VEGAS NV
89130
US

V. Phone/Fax

Practice location:
  • Phone: 602-864-3656
  • Fax: 602-864-3660
Mailing address:
  • Phone: 702-395-5011
  • Fax: 702-645-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ABBY GROSSA
Title or Position: CFO
Credential:
Phone: 702-395-5011