Provider Demographics
NPI:1245590140
Name:SOURCE DIAGNOSTICS OF SOUTH CAROLINA, LLC
Entity Type:Organization
Organization Name:SOURCE DIAGNOSTICS OF SOUTH CAROLINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-645-7822
Mailing Address - Street 1:5275 NAIMAN PKWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1029
Mailing Address - Country:US
Mailing Address - Phone:440-645-7822
Mailing Address - Fax:
Practice Address - Street 1:2701 S OCEAN BLVD
Practice Address - Street 2:UNIT 1831
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4641
Practice Address - Country:US
Practice Address - Phone:440-645-7822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier