Healthcare Provider Details

I. General information

NPI: 1104823368
Provider Name (Legal Business Name): QUALITY MEDICAL IMAGING OF NEVADA LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2005
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 PROFESSIONAL CT SUITE 110
LAS VEGAS NV
89128-0825
US

IV. Provider business mailing address

2490 PROFESSIONAL CT SUITE 110
LAS VEGAS NV
89128-0825
US

V. Phone/Fax

Practice location:
  • Phone: 702-839-1133
  • Fax: 702-851-1616
Mailing address:
  • Phone: 702-839-1133
  • Fax: 702-851-1616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License NumberLLC5073-2001
License Number StateNV

VIII. Authorized Official

Name: MR. ROGER C FASELT
Title or Position: PRESIDENT
Credential:
Phone: 702-839-1133