Healthcare Provider Details

I. General information

NPI: 1477598266
Provider Name (Legal Business Name): ONE SOURCE DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 W PACIFIC AVE
HENDERSON NV
89015-7304
US

IV. Provider business mailing address

11 W PACIFIC AVE
HENDERSON NV
89015-7304
US

V. Phone/Fax

Practice location:
  • Phone: 702-568-6433
  • Fax: 702-568-6299
Mailing address:
  • Phone: 702-568-6433
  • Fax: 702-568-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number1003036295
License Number StateNV

VIII. Authorized Official

Name: MRS. ROSA DIAZ PADILLA
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 702-568-0007