Provider Demographics
NPI:1235169301
Name:NATIONAL PET CENTERS LLC
Entity Type:Organization
Organization Name:NATIONAL PET CENTERS LLC
Other - Org Name:GREAT LAKES MEDICAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-274-2844
Mailing Address - Street 1:5313 DONA ROAD
Mailing Address - Street 2:
Mailing Address - City:JULIAN
Mailing Address - State:NC
Mailing Address - Zip Code:27283
Mailing Address - Country:US
Mailing Address - Phone:336-274-2844
Mailing Address - Fax:336-274-2817
Practice Address - Street 1:19250 BAGLEY ROAD, SUITE 203
Practice Address - Street 2:NATIONAL PET CENTERS LLC DBA GREAT LAKES MEDICAL IMAGIN
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130
Practice Address - Country:US
Practice Address - Phone:440-234-3321
Practice Address - Fax:440-234-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093798720OtherRENDERING PROVIDER NUMBERS
OH2326478Medicaid
1275583791OtherRENDERING PROVIDER NUMBER
192232OtherANTHEM BLUE SHIELD
192322OtherANTHEM BC/BS
1093798720OtherRENDERING PROVIDER NUMBERS
OH2326478Medicaid
100673Medicare PIN