Healthcare Provider Details

I. General information

NPI: 1639673965
Provider Name (Legal Business Name): ADVANCED DIAGNOSTIC IMAGING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 MEDICAL DR
LAFAYETTE TN
37083-1719
US

IV. Provider business mailing address

3024 BUSINESS PARK CIR
GOODLETTSVILLE TN
37072-3132
US

V. Phone/Fax

Practice location:
  • Phone: 615-220-8788
  • Fax: 615-220-8688
Mailing address:
  • Phone: 615-851-6033
  • Fax: 615-851-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: SUSAN FENTON
Title or Position: DO
Credential:
Phone: 615-851-6033