Healthcare Provider Details

I. General information

NPI: 1649398751
Provider Name (Legal Business Name): PROFESSIONAL ULTRASOUND & IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MEMORY PLZ
WHITEVILLE NC
28472-2640
US

IV. Provider business mailing address

PO BOX 434
CHADBOURN NC
28431-0434
US

V. Phone/Fax

Practice location:
  • Phone: 910-914-6154
  • Fax: 910-914-6156
Mailing address:
  • Phone: 910-620-9097
  • Fax: 910-623-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number112625
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number279513
License Number StateNC

VIII. Authorized Official

Name: MRS. CHRISTIAN HORTON LANE
Title or Position: OWNER
Credential: RTR, RCS
Phone: 910-620-9097