Healthcare Provider Details

I. General information

NPI: 1972744522
Provider Name (Legal Business Name): FAMILY MEDICAL IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MALLARD CT
BECKLEY WV
25801
US

IV. Provider business mailing address

25 MALLARD CT
BECKLEY WV
25801-3664
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-2527
  • Fax: 304-255-5675
Mailing address:
  • Phone: 304-255-2527
  • Fax: 304-255-5675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1002-2421
License Number StateWV

VIII. Authorized Official

Name: DR. GARY POLING
Title or Position: MEMBER
Credential: D.O.
Phone: 304-255-2527