Provider Demographics
NPI:1699860130
Name:ELITE MRI OF LAURENS, LLC
Entity Type:Organization
Organization Name:ELITE MRI OF LAURENS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:O
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:478-275-8895
Mailing Address - Street 1:P.O. BOX 4003
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208
Mailing Address - Country:US
Mailing Address - Phone:478-755-9966
Mailing Address - Fax:478-755-9964
Practice Address - Street 1:113 FAIRVIEW PARK DRIVE
Practice Address - Street 2:#A
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-275-8895
Practice Address - Fax:478-275-8896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00386876Medicare PIN
GA47BBBQFMedicare PIN