Healthcare Provider Details

I. General information

NPI: 1376650820
Provider Name (Legal Business Name): FAIRWAY IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PINNACLE PARKWAY SUITE 5
COVINGTON LA
70433-9169
US

IV. Provider business mailing address

1200 PINNACLE PARKWAY SUITE 5
COVINGTON LA
70433-9169
US

V. Phone/Fax

Practice location:
  • Phone: 985-809-6744
  • Fax: 965-809-6745
Mailing address:
  • Phone: 985-809-6744
  • Fax: 985-809-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MONICA RESTER
Title or Position: ADMINISTRATOR
Credential:
Phone: 985-809-6744