Healthcare Provider Details

I. General information

NPI: 1518027507
Provider Name (Legal Business Name): DIAGNOSTIC MOBILE XRAY OF ENID
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 S COLTRANE RD
EDMOND OK
73034-6730
US

IV. Provider business mailing address

PO BOX 3637
EDMOND OK
73083-3637
US

V. Phone/Fax

Practice location:
  • Phone: 405-330-0055
  • Fax:
Mailing address:
  • Phone: 405-330-0055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. ELIZABETH BORGERT
Title or Position: PRESIDENT
Credential:
Phone: 405-330-0055