Provider Demographics
NPI:1942751110
Name:UPSCALE ULTRASOUND & MOBILE 3D 4D, LLC
Entity Type:Organization
Organization Name:UPSCALE ULTRASOUND & MOBILE 3D 4D, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:904-465-9062
Mailing Address - Street 1:145 HILDEN RD
Mailing Address - Street 2:STE 113
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8401
Mailing Address - Country:US
Mailing Address - Phone:904-465-9062
Mailing Address - Fax:
Practice Address - Street 1:145 HILDEN RD
Practice Address - Street 2:STE 113
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-8401
Practice Address - Country:US
Practice Address - Phone:904-465-9062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPSCALE ULTRASOUND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL134780261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1871951244OtherINDIVIDUAL NPI