1154784205 NPI number — MED VENTURES MRI, LLC

Table of content: (NPI 1154784205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154784205 NPI number — MED VENTURES MRI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED VENTURES MRI, 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:
1154784205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1975 HWY 54 W.
Provider Second Line Business Mailing Address:
STE 205
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-4794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-561-9000
Provider Business Mailing Address Fax Number:
770-487-1232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 LAFAYETTE PARKWAY
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-845-9370
Provider Business Practice Location Address Fax Number:
706-845-9371
Provider Enumeration Date:
04/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLSTROM
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
706-594-0687

Provider Taxonomy Codes

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

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





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