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General NPI Number Information
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NPI Number | 1225640329
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Entity Type | Organization
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Legal Business Name | EASTSIDE DIAGNOSTICS LLC
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Dates
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Enumeration Date | 08/19/2020
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Last Update Date | 08/19/2020
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Provider Practice Location Address
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Address Line | 25100 KELLY RD STE B
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City | ROSEVILLE
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State | MI
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Zip | 48066-4910
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Country | US
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Telephone | 248-262-7379
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Fax |
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Provider Business Mailing Address
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Address Line | 22000 GREENFIELD RD
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City | OAK PARK
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State | MI
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Zip | 48237-2500
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Country | US
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Telephone | 248-709-7072
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JENNIFER WATSON
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Credential | NP-C
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Telephone | 248-709-7072
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0208X
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Taxonomy Name | Mobile Radiology Clinic/Center
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License Number |
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License Number State |
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