Provider Demographics
NPI:1902934110
Name:COM-RAD MOBILE IMAGING, LLC
Entity type:Organization
Organization Name:COM-RAD MOBILE IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-650-8353
Mailing Address - Street 1:339 BENWOOD TRL NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37323-5096
Mailing Address - Country:US
Mailing Address - Phone:423-650-8353
Mailing Address - Fax:336-245-0649
Practice Address - Street 1:339 BENWOOD TRL NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323-5096
Practice Address - Country:US
Practice Address - Phone:423-650-8353
Practice Address - Fax:336-245-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-07-19
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
TN3400012Medicaid
TN3400012Medicaid