Healthcare Provider Details

I. General information

NPI: 1841283306
Provider Name (Legal Business Name): PORTARAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7460 CHASE LANE
JEFFERSONVILLE KY
40337-8979
US

IV. Provider business mailing address

7460 CHASE LANE
JEFFERSONVILLE KY
40337-8979
US

V. Phone/Fax

Practice location:
  • Phone: 866-972-9626
  • Fax: 859-498-6007
Mailing address:
  • Phone: 866-972-9626
  • Fax: 859-498-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number720223
License Number StateKY

VIII. Authorized Official

Name: CLAUDE MARTIN JR.
Title or Position: PRESIDENT
Credential: RTR
Phone: 859-585-8992