Healthcare Provider Details

I. General information

NPI: 1386698470
Provider Name (Legal Business Name): SOURCE DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5275 NAIMAN PKWY STE E
SOLON OH
44139-1029
US

IV. Provider business mailing address

5275 NAIMAN PKWY STE E
SOLON OH
44139-1029
US

V. Phone/Fax

Practice location:
  • Phone: 440-542-1515
  • Fax: 440-542-9482
Mailing address:
  • Phone: 440-645-7822
  • Fax: 440-542-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246W00000X
TaxonomyCardiology Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberOH03645
License Number StateOH

VIII. Authorized Official

Name: MR. KEITH C MARCHAND
Title or Position: PRESIDENT
Credential:
Phone: 440-645-4626