Provider Demographics
NPI:1477598266
Name:ONE SOURCE DIAGNOSTIC LLC
Entity Type:Organization
Organization Name:ONE SOURCE DIAGNOSTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:DIAZ
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-568-0007
Mailing Address - Street 1:11 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7304
Mailing Address - Country:US
Mailing Address - Phone:702-568-6433
Mailing Address - Fax:702-568-6299
Practice Address - Street 1:11 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7304
Practice Address - Country:US
Practice Address - Phone:702-568-6433
Practice Address - Fax:702-568-6299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1003036295335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1003036295OtherNV STATE BUSINESS LICENSE