Healthcare Provider Details

I. General information

NPI: 1063036408
Provider Name (Legal Business Name): COULEE DIAGNOSTIC RADIOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 HERITAGE BLVD
WEST SALEM WI
54669-9418
US

IV. Provider business mailing address

807 BARSON CT
ONALASKA WI
54650-3603
US

V. Phone/Fax

Practice location:
  • Phone: 608-518-3406
  • Fax:
Mailing address:
  • Phone: 608-518-3406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EMMANUEL OMOBA
Title or Position: MANAGING DIRECTOR
Credential: MD
Phone: 608-518-3406