Provider Demographics
NPI:1447493390
Name:PORTABLE DIAGNOSTIC IMAGING, INC.
Entity type:Organization
Organization Name:PORTABLE DIAGNOSTIC IMAGING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-369-4775
Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE C 62A
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:612-369-4775
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE C 62A
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:612-369-4775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty