Provider Demographics
NPI:1710932603
Name:LARCHMONT IMAGING ASSOCIATES LLC
Entity Type:Organization
Organization Name:LARCHMONT IMAGING ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-362-5391
Mailing Address - Street 1:P.O. BOX 479
Mailing Address - Street 2:1295 ROUTE 38
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-0479
Mailing Address - Country:US
Mailing Address - Phone:609-914-7017
Mailing Address - Fax:609-261-4180
Practice Address - Street 1:210 ARK RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3188
Practice Address - Country:US
Practice Address - Phone:609-261-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3226905Medicaid
NJ3226905Medicaid