Provider Demographics
NPI:1245474022
Name:MEDICAL IMAGING CENTER, LLC
Entity type:Organization
Organization Name:MEDICAL IMAGING CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTORY
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-322-5729
Mailing Address - Street 1:3186 VILLAGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3978
Mailing Address - Country:US
Mailing Address - Phone:910-323-2209
Mailing Address - Fax:910-323-9680
Practice Address - Street 1:3186 VILLAGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3978
Practice Address - Country:US
Practice Address - Phone:910-323-2209
Practice Address - Fax:910-323-9680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLM0075293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912303Medicaid
NC2880621Medicare PIN