Healthcare Provider Details

I. General information

NPI: 1679140313
Provider Name (Legal Business Name): PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 GLENRIDGE DR STE 100
ATLANTA GA
30328-5572
US

IV. Provider business mailing address

755 CLIFF RD E
BURNSVILLE MN
55337-1545
US

V. Phone/Fax

Practice location:
  • Phone: 866-895-2119
  • Fax: 952-890-9025
Mailing address:
  • Phone: 952-915-9779
  • Fax: 952-915-9597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRUCE ALLEN JOHNSON
Title or Position: VP-AO
Credential:
Phone: 303-589-4149