Healthcare Provider Details

I. General information

NPI: 1154574887
Provider Name (Legal Business Name): RADIOLOGIC-ON-SITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 AMBASSADOR CAFFERY PKWY SUITE G-2
LAFAYETTE LA
70503-5280
US

IV. Provider business mailing address

PO BOX 52108
LAFAYETTE LA
70505-2108
US

V. Phone/Fax

Practice location:
  • Phone: 337-456-3586
  • Fax:
Mailing address:
  • Phone: 337-456-3586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number359485
License Number StateLA

VIII. Authorized Official

Name: JOSHUA A PELLERIN
Title or Position: PRESIDENT
Credential:
Phone: 337-456-3586