MEDICARE: PORTABLE X-RAY OF UTAH 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	261QR0208X	Mobile Radiology Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80990680000001	OTHER	UT	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	80990680000001	OTHER	UT	BLUE SHIELD

General Provider Information

NPI Number	:	1992710669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTABLE X-RAY OF UTAH LLC

Provider Business Mailing Address
First Line	:	5538 DUNCAN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2812
Country	:	US
Telephone Number	:	702-645-2606
Fax Number	:	702-645-2874

Provider Business Practice Location Address
First Line	:	2212 S WEST TEMPLE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2642
Country	:	US
Telephone Number	:	801-359-2532
Fax Number	:	801-485-4174

Authorized Official
Title or Position	:	CFO
Name	:	ABBY GROSSA
Credential	:
Telephone Number	:	702-395-5011

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	04/20/2008

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Directions to “PORTABLE X-RAY OF UTAH LLC ” Practice Location

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