Provider Demographics
NPI:1477693265
Name:EXTENDED CARE DIAGNOSTICS LLC INC
Entity Type:Organization
Organization Name:EXTENDED CARE DIAGNOSTICS LLC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERTIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:GANOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-557-6165
Mailing Address - Street 1:4422 CARVER WOODS DR STE 6
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5536
Mailing Address - Country:US
Mailing Address - Phone:513-891-3181
Mailing Address - Fax:513-891-3934
Practice Address - Street 1:4422 CARVER WOODS DR STE 6
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-5536
Practice Address - Country:US
Practice Address - Phone:513-891-3181
Practice Address - Fax:513-891-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH630001723OtherRR MEDICARE
OH2161315Medicaid
OH3698611Medicare ID - Type Unspecified