Healthcare Provider Details

I. General information

NPI: 1093002776
Provider Name (Legal Business Name): RAD ONE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12462 KROME AVE
PORT CHARLOTTE FL
33981-1327
US

IV. Provider business mailing address

12462 KROME AVE
PORT CHARLOTTE FL
33981-1327
US

V. Phone/Fax

Practice location:
  • Phone: 941-815-1103
  • Fax: 239-541-5445
Mailing address:
  • Phone: 941-815-1103
  • Fax: 239-541-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberCRT39038
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberCRT8522
License Number StateFL

VIII. Authorized Official

Name: DAVID COURSON
Title or Position: PARTNER
Credential: MS.RTR.
Phone: 941-815-1103