=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104823368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITY MEDICAL IMAGING OF NEVADA LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2005
-----------------------------------------------------
Last Update Date | 05/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2490 PROFESSIONAL CT SUITE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-839-1133
-----------------------------------------------------
Fax | 702-851-1616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2490 PROFESSIONAL CT SUITE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-839-1133
-----------------------------------------------------
Fax | 702-851-1616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROGER C FASELT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-839-1133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number | LLC5073-2001
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------