Provider Demographics
NPI:1306878996
Name:MOUNTAIN MOBILE DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:MOUNTAIN MOBILE DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:B
Authorized Official - Last Name:SPURLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RT (R)
Authorized Official - Phone:606-487-9114
Mailing Address - Street 1:PO BOX 896
Mailing Address - Street 2:
Mailing Address - City:BULAN
Mailing Address - State:KY
Mailing Address - Zip Code:41722-0896
Mailing Address - Country:US
Mailing Address - Phone:606-487-9114
Mailing Address - Fax:606-487-9114
Practice Address - Street 1:725 HARDBURLY RD
Practice Address - Street 2:
Practice Address - City:BULAN
Practice Address - State:KY
Practice Address - Zip Code:41722-8907
Practice Address - Country:US
Practice Address - Phone:606-487-9114
Practice Address - Fax:606-487-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY720142335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY86089034Medicaid
KY000000073435OtherANTHEM BC & BS
KY155799OtherUMWA
KY630001411OtherPALMETTO GBA, RRMC
KY630001411OtherPALMETTO GBA, RRMC