Provider Demographics
NPI:1548227523
Name:PET IMAGING OF SOUTHWEST LOUISIANA, LLC
Entity Type:Organization
Organization Name:PET IMAGING OF SOUTHWEST LOUISIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:REMY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-493-5310
Mailing Address - Street 1:600 BAYOU PINES EAST
Mailing Address - Street 2:STE A
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601
Mailing Address - Country:US
Mailing Address - Phone:337-493-5310
Mailing Address - Fax:337-493-8524
Practice Address - Street 1:600 BAYOU PINES EAST
Practice Address - Street 2:STE A
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-493-5310
Practice Address - Fax:337-493-8524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CK63Medicare PIN