Healthcare Provider Details

I. General information

NPI: 1053302042
Provider Name (Legal Business Name): MOBILE MEDICAL RADIOGRAPHY AND EKG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 RHODE ISLAND RD CLEAR POND OFFICES
LAKEVILLE MA
02347-1370
US

IV. Provider business mailing address

109 RHODE ISLAND RD CLEAR POND OFFICES
LAKEVILLE MA
02347-1370
US

V. Phone/Fax

Practice location:
  • Phone: 508-923-6171
  • Fax: 508-923-6248
Mailing address:
  • Phone: 508-923-6171
  • Fax: 508-923-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number08305
License Number StateMA

VIII. Authorized Official

Name: MRS. MINDA DE MEDEIROS
Title or Position: VP OF ADMINISTRATIVE SERVICES
Credential: MHA
Phone: 508-923-6171