Provider Demographics
NPI:1780687798
Name:LIFESCAN IMAGING, LLC
Entity Type:Organization
Organization Name:LIFESCAN IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-403-1401
Mailing Address - Street 1:607 CLIFTY ST
Mailing Address - Street 2:STE 102
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1765
Mailing Address - Country:US
Mailing Address - Phone:606-677-6664
Mailing Address - Fax:606-677-6560
Practice Address - Street 1:607 CLIFTY ST
Practice Address - Street 2:STE 102
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1765
Practice Address - Country:US
Practice Address - Phone:606-677-6664
Practice Address - Fax:606-677-6560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100090800Medicaid
KY65940322Medicaid
KY65940322Medicaid