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General NPI Number Information
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NPI Number | 1750699005
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Entity Type | Organization
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Legal Business Name | PET IMAGING CENTER OF GWINNETT LLC
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Dates
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Enumeration Date | 09/21/2010
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Last Update Date | 09/21/2010
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Provider Practice Location Address
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Address Line | 555 OLD NORCROSS RD 115
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-8716
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Country | US
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Telephone | 770-277-0501
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Fax | 770-277-4324
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Provider Business Mailing Address
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Address Line | 1275 HIGHWAY 54 W 103
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4549
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Country | US
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Telephone | 770-692-1387
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Fax | 770-692-2373
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Authorized Official
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Title or Position | DIRECTOR OF PATIENT ACCOUNTS
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Name | CRYSTAL GATES
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Credential |
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Telephone | 770-692-1387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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