Provider Demographics
NPI:1447596747
Name:MORAN DIAGNOSTIC SERVICES, LLC
Entity Type:Organization
Organization Name:MORAN DIAGNOSTIC SERVICES, LLC
Other - Org Name:PHYSICIANS MOBILE IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-902-5759
Mailing Address - Street 1:PO BOX 634
Mailing Address - Street 2:
Mailing Address - City:LAKE ODESSA
Mailing Address - State:MI
Mailing Address - Zip Code:48849-0634
Mailing Address - Country:US
Mailing Address - Phone:616-902-5759
Mailing Address - Fax:616-773-1292
Practice Address - Street 1:777 JORDAN LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1217
Practice Address - Country:US
Practice Address - Phone:616-902-5759
Practice Address - Fax:616-773-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID5394A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory