Healthcare Provider Details

I. General information

NPI: 1699876706
Provider Name (Legal Business Name): BISTATE DIAGNOSTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR2 BOX 26 RIVERBEND EST
BLUEFIELD VA
24605-0784
US

IV. Provider business mailing address

PO BOX 784
BLUEFIELD VA
24605-0784
US

V. Phone/Fax

Practice location:
  • Phone: 276-322-4520
  • Fax: 276-322-4520
Mailing address:
  • Phone: 276-322-4520
  • Fax: 276-322-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number0101034219
License Number StateVA

VIII. Authorized Official

Name: MR. REYNALDO DUIGUAN JOSE
Title or Position: PARTNER OWNER
Credential: MD
Phone: 276-322-4520