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NPI Code Detail

MEDICARE: DWAYNE R COOK HERITAGE MOBILE X-RAY

MEDICARE: DWAYNE R COOK HERITAGE MOBILE X-RAY
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
1335V00000XPortable X-ray and/or Other Portable Diagnostic Imaging Supplier0120 002367VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1588838817
Entity Type Code : Organization
Provider Name (Legal Business Name) : DWAYNE R COOK HERITAGE MOBILE X-RAY
Provider Business Mailing Address
First Line : PO BOX 2145
Second Line :
City : CHESAPEAKE
State : VA
Zip : 23327-2145
Country : US
Telephone Number : 757-466-1163
Fax Number : 757-466-1178
Provider Business Practice Location Address
First Line : 6330 N CENTER DR
Second Line : SUITE 107
City : NORFOLK
State : VA
Zip : 23502-4008
Country : US
Telephone Number : 757-466-1163
Fax Number : 757-466-1178
Authorized Official
Title or Position : OWNER
Name : MR. DWAYNE ROBERT COOK I
Credential : RT
Telephone Number : 757-580-6040
Provider Enumeration Date : 04/17/2008
Last Update Date : 05/31/2011

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Directions to “DWAYNE R COOK HERITAGE MOBILE X-RAY ” Practice Location

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