Provider Demographics
NPI:1457480832
Name:MAGGIES ENTERPRISES LLC
Entity Type:Organization
Organization Name:MAGGIES ENTERPRISES LLC
Other - Org Name:LOG MOUNTAIN DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-269-7146
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-0475
Mailing Address - Country:US
Mailing Address - Phone:606-269-7146
Mailing Address - Fax:606-337-8839
Practice Address - Street 1:102 MOUNTAIN VIEW CMNS
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-8708
Practice Address - Country:US
Practice Address - Phone:606-269-7146
Practice Address - Fax:606-337-8839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY142920261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100016810Medicaid
KY7100016810Medicaid