Healthcare Provider Details

I. General information

NPI: 1841283751
Provider Name (Legal Business Name): LUMBERTON RADIOLOGICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 WEST 27TH STREET
LUMBERTON NC
28358-3016
US

IV. Provider business mailing address

P.O. BOX 1527
LUMBERTON NC
28359-1527
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-8222
  • Fax: 910-671-0846
Mailing address:
  • Phone: 910-738-8222
  • Fax: 910-671-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM GROVER GODWIN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 910-738-8222