Provider Demographics
NPI:1790489326
Name:PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC
Entity Type:Organization
Organization Name:PROFESSIONAL PORTABLE RADIOLOGIC SERVICES, INC
Other - Org Name:DYNAMIC MOBILE IMAGING
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 1:3825 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3316
Mailing Address - Country:US
Mailing Address - Phone:303-500-1518
Mailing Address - Fax:
Practice Address - Street 1:1400 HAND AVE STE A
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8195
Practice Address - Country:US
Practice Address - Phone:303-500-1518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier