Healthcare Provider Details

I. General information

NPI: 1790983971
Provider Name (Legal Business Name): APPOMATTOX IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SOUTH AVE SUITE 101
COLONIAL HEIGHTS VA
23834-3621
US

IV. Provider business mailing address

930 SOUTH AVE SUITE 101
COLONIAL HEIGHTS VA
23834-3621
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-2340
  • Fax: 804-272-8752
Mailing address:
  • Phone: 804-524-2340
  • Fax: 804-272-8752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LAVELLE R HARDIN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 615-344-8203