Provider Demographics
NPI:1700330883
Name:PRESTIGE DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:PRESTIGE DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:203-627-7478
Mailing Address - Street 1:60 YOWAGO AVE
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-5543
Mailing Address - Country:US
Mailing Address - Phone:203-627-7478
Mailing Address - Fax:
Practice Address - Street 1:60 YOWAGO AVE
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-5543
Practice Address - Country:US
Practice Address - Phone:203-627-7478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology