=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780687798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESCAN IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 01/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 CLIFTY ST STE 102
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-1765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-677-6664
-----------------------------------------------------
Fax | 606-677-6560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 607 CLIFTY ST STE 102
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-1765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-677-6664
-----------------------------------------------------
Fax | 606-677-6560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | MRS. MICHELLE DOUGLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-403-1401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------