Healthcare Provider Details

I. General information

NPI: 1336529197
Provider Name (Legal Business Name): TWINCITY MEDICAL MOBILE DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 STRATFORD CT
WINSTON SALEM NC
27103
US

IV. Provider business mailing address

163 STRATFORD CT
WINSTON SALEM NC
27103-1836
US

V. Phone/Fax

Practice location:
  • Phone: 336-816-6800
  • Fax: 888-507-6778
Mailing address:
  • Phone: 336-816-6800
  • Fax: 888-507-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number21159
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number21159
License Number StateNC

VIII. Authorized Official

Name: MR. RICHARD O. CORNWALL
Title or Position: PRESIDENT
Credential: PA-C
Phone: 336-816-6800