Healthcare Provider Details

I. General information

NPI: 1487801429
Provider Name (Legal Business Name): SOUTHEAST IMAGING SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 RANDOLPH RD
DRUMMONDS TN
38023-6643
US

IV. Provider business mailing address

89 RANDOLPH ROAD
DRUMMONDS TN
38023
US

V. Phone/Fax

Practice location:
  • Phone: 901-603-8553
  • Fax: 901-475-1140
Mailing address:
  • Phone: 901-476-0340
  • Fax: 901-476-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALECIA D BOWERS
Title or Position: OWNER/MEMBER
Credential:
Phone: 901-476-0340