Provider Demographics
NPI:1083692032
Name:PORTABLE X RAY OF SOUTHERN NEVADA
Entity Type:Organization
Organization Name:PORTABLE X RAY OF SOUTHERN NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-939-6559
Mailing Address - Street 1:5538 DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2812
Mailing Address - Country:US
Mailing Address - Phone:702-645-2606
Mailing Address - Fax:702-645-1478
Practice Address - Street 1:5488 DUNCAN DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2812
Practice Address - Country:US
Practice Address - Phone:702-655-0535
Practice Address - Fax:702-655-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV3524OtherNV BLUE SHIELD
=========OtherCHAMPUS SC
NVNV3524OtherNV BLUE SHIELD
NVV9X0009801Medicare PIN