Provider Demographics
NPI:1790983971
Name:APPOMATTOX IMAGING LLC
Entity Type:Organization
Organization Name:APPOMATTOX IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:930 SOUTH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3621
Mailing Address - Country:US
Mailing Address - Phone:804-524-2340
Mailing Address - Fax:804-272-8752
Practice Address - Street 1:930 SOUTH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3621
Practice Address - Country:US
Practice Address - Phone:804-524-2340
Practice Address - Fax:804-272-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography