Provider Demographics
NPI:1922343243
Name:CITADEL TERRACE IMAGING , LLC
Entity Type:Organization
Organization Name:CITADEL TERRACE IMAGING , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOLLNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-574-1741
Mailing Address - Street 1:709 CITADEL DR E
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5302
Mailing Address - Country:US
Mailing Address - Phone:719-596-6688
Mailing Address - Fax:
Practice Address - Street 1:709 CITADEL DR E
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5302
Practice Address - Country:US
Practice Address - Phone:719-596-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology