=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366915738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI- COUNTY MOBILE X-RAY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 01/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 693 COUNTY ROAD 1343
-----------------------------------------------------
City | VINEMONT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-739-2051
-----------------------------------------------------
Fax | 256-841-6399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 305
-----------------------------------------------------
City | VINEMONT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-739-2051
-----------------------------------------------------
Fax | 256-841-6399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DENNIS CARROLL CORRY
-----------------------------------------------------
Credential | RT
-----------------------------------------------------
Telephone | 256-338-3893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------