Provider Demographics
NPI:1326437989
Name:EXECUTIVE IMAGE, INC.
Entity Type:Organization
Organization Name:EXECUTIVE IMAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-918-6328
Mailing Address - Street 1:470 W HANES MILL RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-9102
Mailing Address - Country:US
Mailing Address - Phone:336-918-6328
Mailing Address - Fax:800-840-4241
Practice Address - Street 1:470 W HANES MILL RD
Practice Address - Street 2:SUITE 107
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-9102
Practice Address - Country:US
Practice Address - Phone:336-918-6328
Practice Address - Fax:800-840-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409805Medicaid
2530321OtherMEDICARE PTAN