Healthcare Provider Details

I. General information

NPI: 1053341032
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WHITNEY RANCH DR B9
HENDERSON NV
89014-2611
US

IV. Provider business mailing address

700 E WARM SPRINGS RD 301
LAS VEGAS NV
89119-4305
US

V. Phone/Fax

Practice location:
  • Phone: 702-933-1315
  • Fax: 702-933-1307
Mailing address:
  • Phone: 702-932-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MALISSA THATCHER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-932-8547