Provider Demographics
NPI:1801089800
Name:LIFE DIAGNOSTIC IMAGING LLC
Entity type:Organization
Organization Name:LIFE DIAGNOSTIC IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:DIGERONIMO
Authorized Official - Suffix:
Authorized Official - Credentials:BBA,RDCS
Authorized Official - Phone:757-963-6295
Mailing Address - Street 1:1011 COPPER STONE CIR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-8274
Mailing Address - Country:US
Mailing Address - Phone:757-617-3398
Mailing Address - Fax:
Practice Address - Street 1:1020 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5500
Practice Address - Country:US
Practice Address - Phone:757-963-6295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center