Healthcare Provider Details

I. General information

NPI: 1497239024
Provider Name (Legal Business Name): ADVANCE DIAGNOSTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 VILLAGE DR STE 201
FAYETTEVILLE NC
28304-3864
US

IV. Provider business mailing address

1766 METROMEDICAL DR
FAYETTEVILLE NC
28304-3861
US

V. Phone/Fax

Practice location:
  • Phone: 910-964-4995
  • Fax: 919-367-3399
Mailing address:
  • Phone: 910-964-4995
  • Fax: 919-367-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA SULLIVAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 910-964-4995