1154565802 NPI number — SOUTHEAST X-RAY, INC.

Table of content: (NPI 1154565802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154565802 NPI number — SOUTHEAST X-RAY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST X-RAY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154565802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 N 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OZARK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72949-2053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-667-4000
Provider Business Mailing Address Fax Number:
479-667-9729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 N 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OZARK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72949-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-667-4000
Provider Business Practice Location Address Fax Number:
479-667-9729
Provider Enumeration Date:
04/24/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KUNA
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
479-667-4000

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)