=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376650820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRWAY IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 04/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 PINNACLE PARKWAY SUITE 5
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-9169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-809-6744
-----------------------------------------------------
Fax | 965-809-6745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 PINNACLE PARKWAY SUITE 5
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-9169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-809-6744
-----------------------------------------------------
Fax | 985-809-6745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MONICA RESTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-809-6744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------