1295713758 NPI number — CT AND OPEN MRI LAGRANGE,LLC

Table of content: (NPI 1295713758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295713758 NPI number — CT AND OPEN MRI LAGRANGE,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CT AND OPEN MRI LAGRANGE,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:
1295713758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 E ADAMS ST
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
LA GRANGE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40031-1278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-222-3281
Provider Business Mailing Address Fax Number:
502-225-5796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E ADAMS ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-1278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-3281
Provider Business Practice Location Address Fax Number:
502-225-5796
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AARON
Authorized Official First Name:
JANNICE
Authorized Official Middle Name:
OWENS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
502-222-3281

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CK2568 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65937781 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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