=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386981710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGE STAFFING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2013
-----------------------------------------------------
Last Update Date | 01/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10011 SOUTHMOOR LN
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29707-9117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-390-6607
-----------------------------------------------------
Fax | 704-276-6444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10011 SOUTHMOOR LN
-----------------------------------------------------
City | FORT MILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29707-9117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-390-6607
-----------------------------------------------------
Fax | 704-276-6444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. SERGIO KHOMYAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-390-6607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------