Provider Demographics
NPI:1467875229
Name:PROVIDENCE HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH NETWORK LLC
Other - Org Name:LAUREL IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-256-5300
Mailing Address - Street 1:2750 LAUREL ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-799-9035
Mailing Address - Fax:803-799-9710
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:SUITE 104
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2038
Practice Address - Country:US
Practice Address - Phone:803-799-9035
Practice Address - Fax:803-799-9710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISTERS OF CHARITY PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-30
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40-59972085R0202X, 293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty