Provider Demographics
NPI:1194854224
Name:CLINTON DIAGNOSTIC, LLC
Entity Type:Organization
Organization Name:CLINTON DIAGNOSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUFFARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-226-4147
Mailing Address - Street 1:43475 DALCOMA DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3591
Mailing Address - Country:US
Mailing Address - Phone:586-226-4147
Mailing Address - Fax:
Practice Address - Street 1:43475 DALCOMA DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3591
Practice Address - Country:US
Practice Address - Phone:586-226-4147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P02610Medicare ID - Type Unspecified