Healthcare Provider Details

I. General information

NPI: 1124658299
Provider Name (Legal Business Name): CITY MOBILE ULTRASOUND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 RICHMOND DR SE
ALBUQUERQUE NM
87106-2328
US

IV. Provider business mailing address

308A CAMINO DEL SOL
ESPANOLA NM
87532-2568
US

V. Phone/Fax

Practice location:
  • Phone: 504-512-3237
  • Fax:
Mailing address:
  • Phone: 504-512-3237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS JUDITH BRECKENRIDGE
Title or Position: OWNER
Credential: RDMS, RVT, RDCS
Phone: 504-512-3237