Healthcare Provider Details

I. General information

NPI: 1467322198
Provider Name (Legal Business Name): PROFESSIONAL IMAGING COLUMBIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FORUM BLVD STE 1E
COLUMBIA MO
65203-2094
US

IV. Provider business mailing address

1050 OLD DES PERES RD STE 30
SAINT LOUIS MO
63131-1873
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone: 314-743-2000
  • Fax: 314-743-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE BROOKS
Title or Position: MANAGING PARTNER
Credential:
Phone: 314-324-3728