MEDICARE: LOUISIANA PET IMAGING OF ALEXANDRIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center	LA10218-L01	LA

General Provider Information

NPI Number	:	1093738478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISIANA PET IMAGING OF ALEXANDRIA, LLC

Provider Business Mailing Address
First Line	:	920 PIERREMONT RD
Second Line	:	SUITE 411
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-2079
Country	:	US
Telephone Number	:	318-424-6486
Fax Number	:	318-424-6487

Provider Business Practice Location Address
First Line	:	5419A JACKSON STREET EXT
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2322
Country	:	US
Telephone Number	:	318-441-2226
Fax Number	:	318-441-2240

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. THOMAS HENRY COCHRAN
Credential	:
Telephone Number	:	318-424-6486

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	08/22/2020

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