Healthcare Provider Details

I. General information

NPI: 1396093910
Provider Name (Legal Business Name): MEDICAL SUPPORT SYSTEMS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NW LOOP 410, SUITE 100
SAN ANTONIO TX
78229
US

IV. Provider business mailing address

7251 W. LAKE MEAD BLVD, SUITE 300
LAS VEGAS NV
89128
US

V. Phone/Fax

Practice location:
  • Phone: 702-461-6094
  • Fax:
Mailing address:
  • Phone: 702-461-6094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberNV19981366358
License Number StateNV

VIII. Authorized Official

Name: MR. RONALD DIVITO
Title or Position: PRESIDENT/CEO
Credential: C.P.A., MBA
Phone: 702-461-6094