Provider Demographics
NPI:1053088195
Name:AQ RENAISSANCE IMAGING LLC
Entity Type:Organization
Organization Name:AQ RENAISSANCE IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BHAVIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-376-6616
Mailing Address - Street 1:275 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3396
Mailing Address - Country:US
Mailing Address - Phone:732-376-6616
Mailing Address - Fax:973-900-8816
Practice Address - Street 1:275 HOBART ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3396
Practice Address - Country:US
Practice Address - Phone:732-376-6616
Practice Address - Fax:973-900-8816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology