Provider Demographics
NPI:1851042915
Name:INTERRA EAST DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:INTERRA EAST DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:803-917-8378
Mailing Address - Street 1:128 MILLPORT CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5573
Mailing Address - Country:US
Mailing Address - Phone:864-315-2627
Mailing Address - Fax:
Practice Address - Street 1:128 MILLPORT CIR STE 200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5573
Practice Address - Country:US
Practice Address - Phone:864-315-2627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty