Provider Demographics
NPI:1801040274
Name:DIRECT DIAGNOSTIC SERVICES, LLC
Entity Type:Organization
Organization Name:DIRECT DIAGNOSTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-396-5634
Mailing Address - Street 1:125 A WAMSUTTA MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-5522
Mailing Address - Country:US
Mailing Address - Phone:828-430-3511
Mailing Address - Fax:828-430-3513
Practice Address - Street 1:4 CARRIAGE LN STE 108
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6048
Practice Address - Country:US
Practice Address - Phone:828-396-5634
Practice Address - Fax:888-818-8707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X
NC293D00000X, 293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8105053Medicaid
SCSL0105Medicaid
NC8105053Medicaid