Provider Demographics
NPI:1679864458
Name:PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC.
Other - Org Name:PROFESSIONAL PORTABLE X-RAY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-AO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-589-4149
Mailing Address - Street 1:755 CLIFF RD E
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1545
Mailing Address - Country:US
Mailing Address - Phone:866-895-2119
Mailing Address - Fax:952-890-9025
Practice Address - Street 1:27065 SUNRISE AVE.
Practice Address - Street 2:UNIT A1
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-5915
Practice Address - Country:US
Practice Address - Phone:866-895-2119
Practice Address - Fax:952-890-9025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN630000003OtherMEDICAREPIN