Provider Demographics
NPI:1356546659
Name:INMED DIAGNOSTICS SERVICES OF SC LLC
Entity type:Organization
Organization Name:INMED DIAGNOSTICS SERVICES OF SC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-241-6100
Mailing Address - Street 1:PO BOX 593869
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32859-3869
Mailing Address - Country:US
Mailing Address - Phone:352-241-6100
Mailing Address - Fax:352-241-6101
Practice Address - Street 1:811 82ND PKWY STE D
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4653
Practice Address - Country:US
Practice Address - Phone:843-692-0040
Practice Address - Fax:843-692-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42D1057507291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ318870006Medicare PIN