Provider Demographics
NPI:1326384306
Name:PORTABLE MEDICAL DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:PORTABLE MEDICAL DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-987-9729
Mailing Address - Street 1:1855 LAKELAND DR
Mailing Address - Street 2:SUITE G10
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4913
Mailing Address - Country:US
Mailing Address - Phone:601-987-9729
Mailing Address - Fax:601-987-0093
Practice Address - Street 1:9047 HOME AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-2855
Practice Address - Country:US
Practice Address - Phone:251-272-1080
Practice Address - Fax:251-272-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL9074OtherSTATE BOARD OF HEALTH IPL LICENSE