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General NPI Number Information
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NPI Number | 1063036408
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Entity Type | Organization
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Legal Business Name | COULEE DIAGNOSTIC RADIOLOGY INC
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Dates
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Enumeration Date | 06/01/2020
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Last Update Date | 06/15/2020
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Provider Practice Location Address
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Address Line | 1580 HERITAGE BLVD
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City | WEST SALEM
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State | WI
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Zip | 54669-9418
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Country | US
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Telephone | 608-518-3406
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Fax |
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Provider Business Mailing Address
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Address Line | 807 BARSON CT
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City | ONALASKA
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State | WI
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Zip | 54650-3603
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Country | US
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Telephone | 608-518-3406
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Fax |
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | EMMANUEL OMOBA
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Credential | MD
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Telephone | 608-518-3406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0206X
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Taxonomy Name | Mammography Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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