Provider Demographics
NPI:1417583162
Name:IMAGINUS DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:IMAGINUS DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-650-9459
Mailing Address - Street 1:5616 WILLIAMSON PL
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17673 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:SPIRO
Practice Address - State:OK
Practice Address - Zip Code:74959-5300
Practice Address - Country:US
Practice Address - Phone:479-650-9459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory