Provider Demographics
NPI:1083891667
Name:LONG BEACH IMAGING CENTER LLC
Entity Type:Organization
Organization Name:LONG BEACH IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-431-0727
Mailing Address - Street 1:120 W PARK AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3301
Mailing Address - Country:US
Mailing Address - Phone:516-431-0727
Mailing Address - Fax:
Practice Address - Street 1:120 W PARK AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3301
Practice Address - Country:US
Practice Address - Phone:516-431-0727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-26
Last Update Date:2008-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty