Provider Demographics
NPI:1386832368
Name:LIFESCAN TENNESSEE, LLC
Entity Type:Organization
Organization Name:LIFESCAN TENNESSEE, LLC
Other - Org Name:MOLECULAR IMAGING ALLIANCE OF TENNESSEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-477-3026
Mailing Address - Street 1:701 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3645
Mailing Address - Country:US
Mailing Address - Phone:423-477-3026
Mailing Address - Fax:423-477-2686
Practice Address - Street 1:830 SUNCREST DR
Practice Address - Street 2:UNIT 2
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-3424
Practice Address - Country:US
Practice Address - Phone:423-477-3026
Practice Address - Fax:423-477-2686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODC0000000042261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3790000Medicaid
TN3790000Medicare PIN