Healthcare Provider Details

I. General information

NPI: 1396270351
Provider Name (Legal Business Name): ZOOM DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 03/07/2020
Certification Date: 03/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 WEST CHERRY AVE
ENID OK
73703
US

IV. Provider business mailing address

1113 W CHERRY AVE
ENID OK
73703-3320
US

V. Phone/Fax

Practice location:
  • Phone: 580-540-3244
  • Fax: 580-308-1023
Mailing address:
  • Phone: 580-540-3244
  • Fax: 580-308-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JERMAINE ANDRE WADE
Title or Position: PRESIDENT
Credential:
Phone: 972-816-5813