MEDICARE: TRINITY 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
1	247100000X	Radiologic Technologist
2	335V00000X	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier

General Provider Information

NPI Number	:	1851641567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY MOBILE X-RAY

Provider Business Mailing Address
First Line	:	6431 WADE SPRINGS RD
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37130-8719
Country	:	US
Telephone Number	:	615-522-1094
Fax Number	:

Provider Business Practice Location Address
First Line	:	6431 WADE SPRINGS RD
Second Line	:
City	:	MURFREESBORO
State	:	TN
Zip	:	37130-8719
Country	:	US
Telephone Number	:	615-522-1094
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	TIMOTHY LEE RUSSELL
Credential	:	R.T.
Telephone Number	:	615-522-1094

Provider Enumeration Date	:	09/11/2012
Last Update Date	:	09/23/2016

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