Provider Demographics
NPI:1750699005
Name:PET IMAGING CENTER OF GWINNETT LLC
Entity type:Organization
Organization Name:PET IMAGING CENTER OF GWINNETT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-692-1387
Mailing Address - Street 1:1275 HIGHWAY 54 W
Mailing Address - Street 2:103
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4549
Mailing Address - Country:US
Mailing Address - Phone:770-692-1387
Mailing Address - Fax:770-692-2373
Practice Address - Street 1:555 OLD NORCROSS RD
Practice Address - Street 2:115
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8716
Practice Address - Country:US
Practice Address - Phone:770-277-0501
Practice Address - Fax:770-277-4324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENT MEDICAL IMAGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology