Provider Demographics
NPI:1831154533
Name:ADVANCED IMAGING CENTER, LLC
Entity type:Organization
Organization Name:ADVANCED IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:H.
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-342-4708
Mailing Address - Street 1:1340 POYDRAS ST
Mailing Address - Street 2:SUITE 1850
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1221
Mailing Address - Country:US
Mailing Address - Phone:504-342-4708
Mailing Address - Fax:504-679-9928
Practice Address - Street 1:1001 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2939
Practice Address - Country:US
Practice Address - Phone:504-883-8995
Practice Address - Fax:504-679-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CH19Medicare ID - Type UnspecifiedGROUP MEDICARE #