1477637767 NPI number — TWIN LAKES MEDICAL IMAGING CONSULTANTS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477637767 NPI number — TWIN LAKES MEDICAL IMAGING CONSULTANTS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN LAKES MEDICAL IMAGING CONSULTANTS, P.C.
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:
1477637767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
531D NORTH CHURCH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVINGSTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-823-7980
Provider Business Mailing Address Fax Number:
931-823-8377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVINGSTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38570-1728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-823-7980
Provider Business Practice Location Address Fax Number:
931-823-8377
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COFFMAN
Authorized Official First Name:
BRIDGET
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
931-823-7980

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  014338 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1505973 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3193668 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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