Healthcare Provider Details

I. General information

NPI: 1770513475
Provider Name (Legal Business Name): MITCHELL DIAGNOSTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 N KIMBALL ST STE 600
MITCHELL SD
57301-5335
US

IV. Provider business mailing address

2250 N KIMBALL ST STE 600
MITCHELL SD
57301-5335
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-2031
  • Fax: 605-996-4496
Mailing address:
  • Phone: 605-996-2031
  • Fax: 605-996-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number48461
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number48461
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number42168
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License Number42168
License Number StateSD
# 5
Primary TaxonomyN
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number42168
License Number StateSD
# 6
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number43D0407438
License Number StateSD
# 7
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number18136
License Number StateSD

VIII. Authorized Official

Name: MS. MARY PARR
Title or Position: OFFICE MANAGER
Credential:
Phone: 605-996-2031