Healthcare Provider Details

I. General information

NPI: 1104397413
Provider Name (Legal Business Name): PROACTIVE MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2018
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 E PLATTE AVE STE C
FORT MORGAN CO
80701-3172
US

IV. Provider business mailing address

329 E PLATTE AVE STE C
FORT MORGAN CO
80701-3172
US

V. Phone/Fax

Practice location:
  • Phone: 970-415-0855
  • Fax: 720-247-9072
Mailing address:
  • Phone: 970-415-0855
  • Fax: 720-247-9072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Internal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEIF STEPHENS
Title or Position: OWNER
Credential:
Phone: 970-441-1117