Provider Demographics
NPI:1457336174
Name:WACCAMAW ULTRASOUND & DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:WACCAMAW ULTRASOUND & DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GRIGSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-642-9085
Mailing Address - Street 1:112 E WHITE OAK ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-2128
Mailing Address - Country:US
Mailing Address - Phone:910-642-9085
Mailing Address - Fax:910-642-3082
Practice Address - Street 1:619 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3707
Practice Address - Country:US
Practice Address - Phone:910-642-9085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890129LMedicaid
NC2881506AMedicare ID - Type UnspecifiedIDTF