Provider Demographics
NPI:1649855545
Name:EASTSIDE P.E.T. CENTER, LLC
Entity type:Organization
Organization Name:EASTSIDE P.E.T. CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP CORPORATE COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-221-8258
Mailing Address - Street 1:406 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-3400
Mailing Address - Country:US
Mailing Address - Phone:205-221-8200
Mailing Address - Fax:
Practice Address - Street 1:7191 CAHABA VALLEY RD STE 203
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35242-6448
Practice Address - Country:US
Practice Address - Phone:205-221-8200
Practice Address - Fax:205-221-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-11
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic