1184740680 NPI number — INMED DIAGNOSTICS SERVICES OF SC LLC

Table of content: (NPI 1184740680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184740680 NPI number — INMED DIAGNOSTICS SERVICES OF SC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INMED DIAGNOSTICS SERVICES OF SC LLC
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:
1184740680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 E COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 826
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-4054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-510-3700
Provider Business Mailing Address Fax Number:
954-510-2649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4701 OLEANDER DR
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-5762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-692-0040
Provider Business Practice Location Address Fax Number:
843-692-0046
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LONGTON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
954-510-3704

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  85342 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PL0068 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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