MEDICARE: ADVANCED MOBILE DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246XC2903X	Vascular Specialist/Technologist Cardiovascular

General Provider Information

NPI Number	:	1366851271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED MOBILE DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	10808 S RIVER FRONT PKWY STE 362
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-6300
Country	:	US
Telephone Number	:	801-984-8039
Fax Number	:

Provider Business Practice Location Address
First Line	:	10808 S RIVER FRONT PKWY STE 362
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-6300
Country	:	US
Telephone Number	:	801-984-8039
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	DAVID HAGUE
Credential	:
Telephone Number	:	801-558-2822

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	08/05/2014

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