=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801089800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE DIAGNOSTIC IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2007
-----------------------------------------------------
Last Update Date | 02/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 INDEPENDENCE BLVD SUITE 102
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-963-6295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 COPPER STONE CIR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-8274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-617-3398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DREW LAWRENCE DIGERONIMO
-----------------------------------------------------
Credential | BBA,RDCS
-----------------------------------------------------
Telephone | 757-963-6295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------