Provider Demographics
NPI:1629583091
Name:PREMIUM MOBILE DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:PREMIUM MOBILE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ZINATH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:951-272-3372
Mailing Address - Street 1:1014 LOWRY RANCH RD
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-4735
Mailing Address - Country:US
Mailing Address - Phone:951-272-3372
Mailing Address - Fax:
Practice Address - Street 1:11414 W PARK PL STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3500
Practice Address - Country:US
Practice Address - Phone:951-272-3372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier