=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417583162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGINUS DIAGNOSTIC LABORATORY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2020
-----------------------------------------------------
Last Update Date | 07/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17673 US HIGHWAY 271
-----------------------------------------------------
City | SPIRO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74959-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-650-9459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5616 WILLIAMSON PL
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72916-8415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | BRITTANY WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-650-9459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------