Healthcare Provider Details

I. General information

NPI: 1306878996
Provider Name (Legal Business Name): MOUNTAIN MOBILE DIAGNOSTICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 HARDBURLY RD
BULAN KY
41722-8907
US

IV. Provider business mailing address

PO BOX 896
BULAN KY
41722-0896
US

V. Phone/Fax

Practice location:
  • Phone: 606-487-9114
  • Fax: 606-487-9114
Mailing address:
  • Phone: 606-487-9114
  • Fax: 606-487-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number720142
License Number StateKY

VIII. Authorized Official

Name: MR. J B SPURLOCK
Title or Position: PRESIDENT/OWNER
Credential: R.T. (R)
Phone: 606-487-9114