Provider Demographics
NPI:1851476261
Name:CHILDERSBURG DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:CHILDERSBURG DIAGNOSTIC IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-378-3313
Mailing Address - Street 1:P. O. BOX 349 30411
Mailing Address - Street 2:HWY 280
Mailing Address - City:CHILDERSBURG
Mailing Address - State:AL
Mailing Address - Zip Code:35178
Mailing Address - Country:US
Mailing Address - Phone:256-378-3313
Mailing Address - Fax:256-378-3315
Practice Address - Street 1:30411 HWY 280
Practice Address - Street 2:
Practice Address - City:CHILDERSBURG
Practice Address - State:AL
Practice Address - Zip Code:35178
Practice Address - Country:US
Practice Address - Phone:256-378-3313
Practice Address - Fax:256-378-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11948293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory