Healthcare Provider Details

I. General information

NPI: 1164111928
Provider Name (Legal Business Name): DYNAMIC MEDICAL IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W CHESTNUT ST
UNION NJ
07083-6966
US

IV. Provider business mailing address

950 W CHESTNUT ST
UNION NJ
07083-6966
US

V. Phone/Fax

Practice location:
  • Phone: 908-687-2552
  • Fax:
Mailing address:
  • Phone: 908-687-2552
  • Fax: 908-505-9664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZA DELAFUENTECHAVEZ
Title or Position: COO
Credential:
Phone: 908-687-2552