Provider Demographics
NPI:1457305492
Name:OPELOUSAS PET CT IMAGING CENTER LLC
Entity Type:Organization
Organization Name:OPELOUSAS PET CT IMAGING CENTER LLC
Other - Org Name:OPELOUSAS PET CT IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:103 POWELL CT
Mailing Address - Street 2:STE. 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5079
Mailing Address - Country:US
Mailing Address - Phone:615-372-8500
Mailing Address - Fax:615-372-8572
Practice Address - Street 1:3975 I 49 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-407-8881
Practice Address - Fax:337-407-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5DA11Medicare ID - Type UnspecifiedIDTF