Healthcare Provider Details

I. General information

NPI: 1306969621
Provider Name (Legal Business Name): ADVANTAGE DIAGNOSTIC IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 S JONES BLVD SUITE E
LAS VEGAS NV
89146-5656
US

IV. Provider business mailing address

2980 S JONES BLVD SUITE E
LAS VEGAS NV
89146-5656
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-6417
  • Fax: 708-535-8087
Mailing address:
  • Phone: 708-478-6417
  • Fax: 708-535-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. JIM KOLB
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 708-478-6403