=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598872350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADI ADVANCED DIGITAL IMAGING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2006
-----------------------------------------------------
Last Update Date | 03/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 STILES ROAD SUITE 206
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-893-1893
-----------------------------------------------------
Fax | 603-893-2456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1784
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-893-1893
-----------------------------------------------------
Fax | 603-893-2456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MANUEL J SOUSA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 603-893-1893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------