Healthcare Provider Details

I. General information

NPI: 1326102633
Provider Name (Legal Business Name): MOBILE X-RAY OF LOUISIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 COOLIDGE BLVD.
LAFAYETTE LA
70503-0000
US

IV. Provider business mailing address

910 HARDING ST
LAFAYETTE LA
70503-2450
US

V. Phone/Fax

Practice location:
  • Phone: 337-412-6702
  • Fax: 337-504-2158
Mailing address:
  • Phone: 337-412-6702
  • Fax: 337-504-2158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEREMY A. HEBERT
Title or Position: MANAGER
Credential:
Phone: 337-233-1987