Provider Demographics
NPI:1497374557
Name:IMAGE OBSESSION LLC
Entity Type:Organization
Organization Name:IMAGE OBSESSION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-237-8148
Mailing Address - Street 1:1855 E MAIN ST # SR03
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-2309
Mailing Address - Country:US
Mailing Address - Phone:864-237-8148
Mailing Address - Fax:207-255-7679
Practice Address - Street 1:1855 E MAIN ST # SR03
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-2309
Practice Address - Country:US
Practice Address - Phone:864-237-8148
Practice Address - Fax:207-255-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2000027094OtherBUSINESS LICENSE