=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912080441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE WELLNESS IMAGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 10/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7640 SYLVANIA AVE SUITE A-1
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-9729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-517-1700
-----------------------------------------------------
Fax | 417-517-1711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7640 SYLVANIA AVE SUITE A-1
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-9729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-517-1700
-----------------------------------------------------
Fax | 417-517-1711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MRS. DIANE S MORENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-517-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | IOG1038601
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------