1407967565 NPI number — SOUTHEASTERN MOBILE IMAGING LLC

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 1407967565 NPI number — SOUTHEASTERN MOBILE IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN MOBILE 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:
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:
1407967565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1137 ANDREW BROOK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37923-1591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-216-0618
Provider Business Mailing Address Fax Number:
865-637-6376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5004 BAYBERRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37921-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-216-0618
Provider Business Practice Location Address Fax Number:
423-765-0465
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
865-216-0618

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , with the licence number:  NA , 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)





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