Healthcare Provider Details

I. General information

NPI: 1962650424
Provider Name (Legal Business Name): INNOVATIVE MOBILE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 HEATHERVIEW DR
OAK PARK CA
91377-3914
US

IV. Provider business mailing address

PO BOX 2966
JOPLIN MO
64803-2966
US

V. Phone/Fax

Practice location:
  • Phone: 818-879-8037
  • Fax:
Mailing address:
  • Phone: 417-626-9729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number6638
License Number StateCA

VIII. Authorized Official

Name: MICHAEL KELLEY
Title or Position: OWNER
Credential:
Phone: 417-626-9729