=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316729791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMONWEALTH MOBILE MEDICAL IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2023
-----------------------------------------------------
Last Update Date | 10/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 WASHINGTON ST STE C
-----------------------------------------------------
City | HOLLISTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01746-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-956-9698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 770 WASHINGTON ST STE C
-----------------------------------------------------
City | HOLLISTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01746-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER (MANAGER)
-----------------------------------------------------
Name | MR. ADAM A BEZZA
-----------------------------------------------------
Credential | R.T.(R) VI
-----------------------------------------------------
Telephone | 781-956-9698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------