=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457427387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST MOBILE DIAGNOSTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2006
-----------------------------------------------------
Last Update Date | 07/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RR2 RIVERBEND EST NO 26
-----------------------------------------------------
City | BLUEFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24605-0026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-322-4520
-----------------------------------------------------
Fax | 276-322-4520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 797
-----------------------------------------------------
City | NORTH TAZEWELL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24630-0797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-322-4520
-----------------------------------------------------
Fax | 276-322-4520
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MARCELO LAPURGA SANTIAGO JR.
-----------------------------------------------------
Credential | SONAGRAPHER
-----------------------------------------------------
Telephone | 276-322-4520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------