Healthcare Provider Details

I. General information

NPI: 1457417065
Provider Name (Legal Business Name): MEDICAL ARTS DIAGNOSTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 SOUTH RANGE SUITE 2
COLBY KS
67701-0001
US

IV. Provider business mailing address

175 SOUTH RANGE SUITE 2
COLBY KS
67701-0001
US

V. Phone/Fax

Practice location:
  • Phone: 785-462-3332
  • Fax: 785-462-3337
Mailing address:
  • Phone: 785-462-3332
  • Fax: 785-462-3337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. BRENDA HILDYARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 785-462-3332