MEDICARE: ALPHA OMEGA SONOGRAPHY 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	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1588600571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA OMEGA SONOGRAPHY LLC

Provider Business Mailing Address
First Line	:	12402 N DIVISION ST
Second Line	:	SUITE 205
City	:	SPOKANE
State	:	WA
Zip	:	99218-1930
Country	:	US
Telephone Number	:	509-465-2679
Fax Number	:

Provider Business Practice Location Address
First Line	:	12402 N DIVISION ST
Second Line	:	SUITE 205
City	:	SPOKANE
State	:	WA
Zip	:	99218-1930
Country	:	US
Telephone Number	:	509-465-2630
Fax Number	:	509-465-2679

Authorized Official
Title or Position	:	MEMBER
Name	:	MARK LACASELLA
Credential	:
Telephone Number	:	509-465-2630

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	07/02/2008

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