Provider Demographics
NPI:1831529536
Name:VALDOSTA IMAGING CENTER INC
Entity type:Organization
Organization Name:VALDOSTA IMAGING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-242-8790
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-0400
Mailing Address - Country:US
Mailing Address - Phone:229-242-8790
Mailing Address - Fax:229-247-6868
Practice Address - Street 1:704 GIL HARBIN INDUSTRIAL BLVD
Practice Address - Street 2:STE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-6513
Practice Address - Country:US
Practice Address - Phone:229-242-8790
Practice Address - Fax:229-247-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty