Provider Demographics
NPI:1598747628
Name:PRI X-RAY, L.L.C.
Entity Type:Organization
Organization Name:PRI X-RAY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-932-8599
Mailing Address - Street 1:3620 MCGINNIS PARK DR
Mailing Address - Street 2:SUITE #1
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7136
Mailing Address - Country:US
Mailing Address - Phone:770-932-8599
Mailing Address - Fax:770-614-8048
Practice Address - Street 1:3620 MCGINNIS PARK DR
Practice Address - Street 2:SUITE #1
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7136
Practice Address - Country:US
Practice Address - Phone:770-932-8599
Practice Address - Fax:770-614-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00803822AMedicaid
630001384OtherRAILROAD MEDICARE
GA00803822AMedicaid
GA63KCBBZMedicare PIN
GA630001384Medicare PIN