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General NPI Number Information
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NPI Number | 1558346148
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Entity Type | Organization
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Legal Business Name | OPEN AND WIDE MRI, LLC
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Dates
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Enumeration Date | 12/07/2005
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | 3050 WINDSOR CT
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City | ELKHART
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State | IN
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Zip | 46514-5555
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Country | US
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Telephone | 574-266-9222
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Fax | 574-266-9333
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Provider Business Mailing Address
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Address Line | PO BOX 338
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City | LA FONTAINE
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State | IN
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Zip | 46940-0338
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Country | US
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Telephone | 765-228-4660
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Fax | 765-228-4660
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Authorized Official
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Title or Position | PRESIDENT
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Name | GARDNER BARTROM
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Credential |
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Telephone | 765-228-4660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471M1202X
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Taxonomy Name | Magnetic Resonance Imaging Radiologic Technologist
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License Number | 20590
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License Number State | IN
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