Provider Demographics
NPI:1033107966
Name:MMDS OF KINGSPORT, LLC
Entity Type:Organization
Organization Name:MMDS OF KINGSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8093
Mailing Address - Street 1:1038 S WILCOX DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5378
Mailing Address - Country:US
Mailing Address - Phone:423-230-8093
Mailing Address - Fax:423-230-4932
Practice Address - Street 1:1038 S WILCOX DR
Practice Address - Street 2:SUITE 115
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5378
Practice Address - Country:US
Practice Address - Phone:423-230-8093
Practice Address - Fax:423-230-4932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00237335OtherMEDICARE RAIL ROAD
NC2530385Medicare PIN
TN3404409Medicare ID - Type Unspecified