=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124073481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL IMAGING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 05/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 NEW HOPE RD STE 7
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-487-1076
-----------------------------------------------------
Fax | 304-425-9499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1559
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24740-1559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-487-1076
-----------------------------------------------------
Fax | 304-425-9499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT OFFICE MANAGER
-----------------------------------------------------
Name | MS. NANCY LOCKHART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-487-1076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------