Provider Demographics
NPI:1831113927
Name:PROVISION IMAGING OF LAKE COUNTY
Entity Type:Organization
Organization Name:PROVISION IMAGING OF LAKE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MATT
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-842-7768
Mailing Address - Street 1:1601 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118
Mailing Address - Country:US
Mailing Address - Phone:405-842-7768
Mailing Address - Fax:405-842-7789
Practice Address - Street 1:7511 FREDLE DR
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-9406
Practice Address - Country:US
Practice Address - Phone:440-354-3686
Practice Address - Fax:440-354-6708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPRID02721Medicare ID - Type Unspecified