Provider Demographics
NPI:1043213077
Name:KING'S MEDICAL IMAGING AT WATERMARK, LLC
Entity Type:Organization
Organization Name:KING'S MEDICAL IMAGING AT WATERMARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:V.
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:COYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-653-3968
Mailing Address - Street 1:1894 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4058
Mailing Address - Country:US
Mailing Address - Phone:330-653-3968
Mailing Address - Fax:330-656-1660
Practice Address - Street 1:1680 WATERMARK DR
Practice Address - Street 2:STE 101
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1034
Practice Address - Country:US
Practice Address - Phone:614-485-1804
Practice Address - Fax:614-485-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2320698Medicaid
OH2320698Medicaid