Healthcare Provider Details

I. General information

NPI: 1043593395
Provider Name (Legal Business Name): WACCAMAW ULTRASOUND & DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E WHITE OAK ST
LAKE WACCAMAW NC
28450-2128
US

IV. Provider business mailing address

1515 MEDICAL CENTER DR
WILMINGTON NC
28401-7507
US

V. Phone/Fax

Practice location:
  • Phone: 910-642-9085
  • Fax:
Mailing address:
  • Phone: 910-642-9085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY GRIGSBY
Title or Position: PRESIDENT
Credential:
Phone: 910-642-9085