Healthcare Provider Details

I. General information

NPI: 1245283290
Provider Name (Legal Business Name): LAKE REGIONAL IMAGING PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 NICHOLS RD
OSAGE BEACH MO
65065-3093
US

IV. Provider business mailing address

1075 NICHOLS RD
OSAGE BEACH MO
65065-3093
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-6161
  • Fax: 573-348-6162
Mailing address:
  • Phone: 573-348-6161
  • Fax: 573-348-6162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID W. HALSELL
Title or Position: SR. V.P., CFO/AUTHORIZED OFFICIAL
Credential:
Phone: 573-348-8388