Healthcare Provider Details

I. General information

NPI: 1407967565
Provider Name (Legal Business Name): SOUTHEASTERN MOBILE IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 BAYBERRY DR
KNOXVILLE TN
37921-1401
US

IV. Provider business mailing address

1137 ANDREW BROOK LN
KNOXVILLE TN
37923-1591
US

V. Phone/Fax

Practice location:
  • Phone: 865-216-0618
  • Fax: 423-765-0465
Mailing address:
  • Phone: 865-216-0618
  • Fax: 865-637-6376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License NumberNA
License Number StateTN

VIII. Authorized Official

Name: MISS JULIE M WATSON
Title or Position: OWNER
Credential:
Phone: 865-216-0618