Provider Demographics
NPI:1013113638
Name:PHYSICIAN DIAGNOSTIC SERVICES
Entity Type:Organization
Organization Name:PHYSICIAN DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOM
Authorized Official - Prefix:
Authorized Official - First Name:BRENDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANAWADU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-946-0600
Mailing Address - Street 1:PO BOX 1408
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-1408
Mailing Address - Country:US
Mailing Address - Phone:509-946-0600
Mailing Address - Fax:509-943-7909
Practice Address - Street 1:1075 JADWIN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3437
Practice Address - Country:US
Practice Address - Phone:509-946-0600
Practice Address - Fax:509-943-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology