Provider Demographics
NPI:1770574394
Name:RIVERSIDE PORTABLE X-RAY & EKG
Entity type:Organization
Organization Name:RIVERSIDE PORTABLE X-RAY & EKG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DELNEGRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-734-6849
Mailing Address - Street 1:PO BOX 29183
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98228-1183
Mailing Address - Country:US
Mailing Address - Phone:360-734-6849
Mailing Address - Fax:360-671-2602
Practice Address - Street 1:4621 MORGAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-5239
Practice Address - Country:US
Practice Address - Phone:360-734-6849
Practice Address - Fax:360-671-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAXT00000006335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA362715001OtherGROUP HEALTH PROVIDER NUM
WA7072630Medicaid
WA8031783Medicaid
WA=========OtherEIN
WAWA03492Medicare ID - Type UnspecifiedTRADING PARTNER
WA=========OtherEIN