Provider Demographics
NPI:1649398751
Name:PROFESSIONAL ULTRASOUND & IMAGING
Entity Type:Organization
Organization Name:PROFESSIONAL ULTRASOUND & IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:HORTON
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:RTR, RCS
Authorized Official - Phone:910-620-9097
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:CHADBOURN
Mailing Address - State:NC
Mailing Address - Zip Code:28431-0434
Mailing Address - Country:US
Mailing Address - Phone:910-620-9097
Mailing Address - Fax:910-623-1343
Practice Address - Street 1:136 MEMORY PLZ
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2640
Practice Address - Country:US
Practice Address - Phone:910-914-6154
Practice Address - Fax:910-914-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC112625247100000X
NC279513293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological Laboratory
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8105016Medicaid
NC2881779Medicare PIN