Provider Demographics
NPI:1902855307
Name:PRO IMAGING DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:PRO IMAGING DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:CNMT
Authorized Official - Phone:304-522-7000
Mailing Address - Street 1:2547 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-522-7000
Mailing Address - Fax:304-522-7662
Practice Address - Street 1:2547 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1642
Practice Address - Country:US
Practice Address - Phone:304-522-7000
Practice Address - Fax:304-522-7662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246XS1301X, 2471B0102X, 2471N0900X, 2471V0105X
WV610002471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Multi-Specialty
No2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone DensitometryGroup - Multi-Specialty
No2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY86000551Medicaid
WV6804005000Medicaid
WVID00751Medicare PIN