Healthcare Provider Details

I. General information

NPI: 1659425544
Provider Name (Legal Business Name): GULF COAST MOBILE IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 HIGHWAY 190 STE A
COVINGTON LA
70433-4962
US

IV. Provider business mailing address

2490 PROFESSIONAL CT STE 110
LAS VEGAS NV
89128-0835
US

V. Phone/Fax

Practice location:
  • Phone: 337-594-9637
  • Fax:
Mailing address:
  • Phone: 702-839-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number088168
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEANNA FASELT
Title or Position: OWNER
Credential: VICE PRESIDENT
Phone: 702-839-1133