Provider Demographics
NPI:1265786305
Name:PROWAVE DIAGNOSTICS LLC
Entity type:Organization
Organization Name:PROWAVE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-419-3375
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RIDGEDALE
Mailing Address - State:MO
Mailing Address - Zip Code:65739-0130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 PEACH LN
Practice Address - Street 2:
Practice Address - City:RIDGEDALE
Practice Address - State:MO
Practice Address - Zip Code:65739-4182
Practice Address - Country:US
Practice Address - Phone:831-477-6633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IGH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier