Provider Demographics
NPI:1588838817
Name:DWAYNE R COOK HERITAGE MOBILE X-RAY
Entity type:Organization
Organization Name:DWAYNE R COOK HERITAGE MOBILE X-RAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:COOK
Authorized Official - Suffix:I
Authorized Official - Credentials:RT
Authorized Official - Phone:757-580-6040
Mailing Address - Street 1:PO BOX 2145
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23327-2145
Mailing Address - Country:US
Mailing Address - Phone:757-466-1163
Mailing Address - Fax:757-466-1178
Practice Address - Street 1:6330 N CENTER DR
Practice Address - Street 2:SUITE 107
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4008
Practice Address - Country:US
Practice Address - Phone:757-466-1163
Practice Address - Fax:757-466-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0120 002367335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008946752Medicaid
VA630000023Medicare PIN