Healthcare Provider Details

I. General information

NPI: 1649855545
Provider Name (Legal Business Name): EASTSIDE P.E.T. CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7191 CAHABA VALLEY RD BLDG 2 STE 203
HOOVER AL
35242-6448
US

IV. Provider business mailing address

406 MEDICAL CENTER DR
JASPER AL
35501-3400
US

V. Phone/Fax

Practice location:
  • Phone: 205-236-9943
  • Fax: 205-236-9947
Mailing address:
  • Phone: 205-221-8200
  • Fax: 205-221-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA J. WELLS
Title or Position: VICE-PRESIDENT
Credential: CPCO
Phone: 205-221-8258