Healthcare Provider Details

I. General information

NPI: 1619933546
Provider Name (Legal Business Name): LAKELAND NUCLEAR IMAGING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 GRANT ST
NILES MI
49120-2281
US

IV. Provider business mailing address

6720 RED ARROW HWY
COLOMA MI
49038-9703
US

V. Phone/Fax

Practice location:
  • Phone: 269-684-0295
  • Fax: 269-684-0189
Mailing address:
  • Phone: 269-684-0295
  • Fax: 269-684-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. DENNIS MACK
Title or Position: VICE PRESIDENT OF FACILITY & SUPPOR
Credential:
Phone: 269-684-0259