Provider Demographics
NPI:1316015985
Name:BROAD 64 IMAGING LLC
Entity Type:Organization
Organization Name:BROAD 64 IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-996-5119
Mailing Address - Street 1:PO BOX 631146
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1146
Mailing Address - Country:US
Mailing Address - Phone:513-952-5002
Mailing Address - Fax:
Practice Address - Street 1:6605 W BROAD ST
Practice Address - Street 2:SUITE B - GROUND FLOOR
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230
Practice Address - Country:US
Practice Address - Phone:804-281-0215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology