Provider Demographics
NPI:1558304824
Name:CAROLINA DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:CAROLINA DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF TECH
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:RVT, RDCS
Authorized Official - Phone:803-758-6003
Mailing Address - Street 1:1701 DEVONSHIRE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2404
Mailing Address - Country:US
Mailing Address - Phone:803-758-6003
Mailing Address - Fax:803-758-5993
Practice Address - Street 1:1701 DEVONSHIRE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2404
Practice Address - Country:US
Practice Address - Phone:803-758-6003
Practice Address - Fax:803-758-5993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSL0032Medicaid
SC=========OtherBC SC
SCSL0032Medicaid