Provider Demographics
NPI:1104991124
Name:VALLEY DIAGNOSTICS, INC
Entity type:Organization
Organization Name:VALLEY DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-967-6492
Mailing Address - Street 1:PO BOX 9010
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9010
Mailing Address - Country:US
Mailing Address - Phone:479-967-6492
Mailing Address - Fax:479-967-6509
Practice Address - Street 1:2504 W MAIN ST
Practice Address - Street 2:STE H
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2533
Practice Address - Country:US
Practice Address - Phone:479-967-6492
Practice Address - Fax:479-967-6509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
19824Medicare PIN