Healthcare Provider Details

I. General information

NPI: 1669642864
Provider Name (Legal Business Name): DIAGNOSTIC IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 VERNON AVE SO SUITE 300
EDINA MN
55436
US

IV. Provider business mailing address

5021 VERNON AVE SO SUITE 300
EDINA MN
55436
US

V. Phone/Fax

Practice location:
  • Phone: 612-280-9096
  • Fax: 952-920-2377
Mailing address:
  • Phone: 612-280-9096
  • Fax: 952-920-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: MRS. KRISTI ELLEN ANDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 612-280-9096