Healthcare Provider Details

I. General information

NPI: 1063867190
Provider Name (Legal Business Name): JRT RADIOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W MAIN ST
RIVERTON WY
82501-3230
US

IV. Provider business mailing address

428 S. DURBIN SUITE 104
CASPER WY
82601-2818
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-6530
  • Fax: 307-333-0580
Mailing address:
  • Phone: 307-337-4285
  • Fax: 307-333-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number5665A
License Number StateWY

VIII. Authorized Official

Name: MR. ZIAD SKAF
Title or Position: MANAGER
Credential:
Phone: 307-337-4285