Healthcare Provider Details

I. General information

NPI: 1831155571
Provider Name (Legal Business Name): ADVANCED HEALTHCARE DIAGNOSTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 KANELL BLVD SUITE 104
POPLAR BLUFF MO
63901-4045
US

IV. Provider business mailing address

4061 HIGHWAY PP
POPLAR BLUFF MO
63901
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-4017
  • Fax: 573-778-9132
Mailing address:
  • Phone: 573-778-0020
  • Fax: 573-778-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY J CARDA
Title or Position: CEO
Credential: CPA,CMA
Phone: 573-778-0020