Healthcare Provider Details

I. General information

NPI: 1124299490
Provider Name (Legal Business Name): DYSPHAGIA MOBILE IMAGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 CENTRAL AVE STE C
AUGUSTA GA
30904-6246
US

IV. Provider business mailing address

2315 CENTRAL AVE STE C
AUGUSTA GA
30904-6246
US

V. Phone/Fax

Practice location:
  • Phone: 706-496-2161
  • Fax: 866-902-8686
Mailing address:
  • Phone: 706-496-2161
  • Fax: 866-902-8686

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: GORDON JONES
Title or Position: PRESIDENT
Credential: DHA
Phone: 706-496-2161