=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215261383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INMED DIAGNOSTICS SERVICES OF SC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1704 E MAIN ST
-----------------------------------------------------
City | DUNCAN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29334-9708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 964-486-8595
-----------------------------------------------------
Fax | 864-486-8433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 E COMMERCIAL BLVD SUITE 826
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-4054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-510-3700
-----------------------------------------------------
Fax | 954-510-2649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. ROBERT E ADAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-510-3703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 42D1099633
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------