1639335797 NPI number — CAPE FEAR DIAGNOSTIC IMAGING, LLC

Table of content: (NPI 1639335797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639335797 NPI number — CAPE FEAR DIAGNOSTIC IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPE FEAR DIAGNOSTIC IMAGING, 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:
6
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:
1639335797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 933393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-659-1211
Provider Business Mailing Address Fax Number:
336-774-1751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 OLDE WATERFORD WAY
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LELAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28451-4125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-383-6047
Provider Business Practice Location Address Fax Number:
910-383-6210
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SCHAEFER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
C.O.O.
Authorized Official Telephone Number:
770-300-0101

Provider Taxonomy Codes

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

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

  • Identifier: 020XH . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5950412 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 011VW . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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