Healthcare Provider Details

I. General information

NPI: 1629339171
Provider Name (Legal Business Name): SOURCE DIAGNOSTICS OF KENTUCKY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 ENTERPRISE DR
ERLANGER KY
41017-1526
US

IV. Provider business mailing address

5275 NAIMAN PKWY STE E
SOLON OH
44139-1029
US

V. Phone/Fax

Practice location:
  • Phone: 866-512-1515
  • Fax:
Mailing address:
  • Phone: 440-645-7822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN A BARRY
Title or Position: COO
Credential:
Phone: 440-645-7822