Healthcare Provider Details

I. General information

NPI: 1083777882
Provider Name (Legal Business Name): DESOTO DIAGNOSTIC IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9085 SANDIDGE CENTER COVE SUITE 100
OLIVE BRANCH MS
38654-3575
US

IV. Provider business mailing address

9085 SANDIDGE CENTER COVE SUITE 100
OLIVE BRANCH MS
38654-3575
US

V. Phone/Fax

Practice location:
  • Phone: 662-536-1000
  • Fax: 662-893-8824
Mailing address:
  • Phone: 662-536-1000
  • Fax: 662-893-8824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: JOHN M GRAVES
Title or Position: PRESIDENT
Credential:
Phone: 901-516-1410