Provider Demographics
NPI:1740204346
Name:ENTERPRISE OPEN MRI, LLC
Entity Type:Organization
Organization Name:ENTERPRISE OPEN MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOMBERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-684-7156
Mailing Address - Street 1:194 E. REDSTONE AVE. SUITE A
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5348
Mailing Address - Country:US
Mailing Address - Phone:334-684-7156
Mailing Address - Fax:334-684-7709
Practice Address - Street 1:100 PROFESSIONAL LANE SUITE B
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330
Practice Address - Country:US
Practice Address - Phone:334-308-1524
Practice Address - Fax:334-308-1528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
051519465OtherBLUE CROSS
AL051554517Medicaid
AL051554517Medicaid