Provider Demographics
NPI:1942491303
Name:CAROLINA FOREST IMAGING CENTER LLC
Entity Type:Organization
Organization Name:CAROLINA FOREST IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:199 VILLAGE CENTER BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579
Mailing Address - Country:US
Mailing Address - Phone:843-236-7878
Mailing Address - Fax:843-236-6406
Practice Address - Street 1:199 VILLAGE CENTER BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-236-7878
Practice Address - Fax:843-236-6406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4758Medicaid