Basic Information
| Provider Information | |||||||||
| NPI: | 1801823141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTGOMERY IMAGING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 NORMANDIE DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361112732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342884624 | ||||||||
| FaxNumber: | 3342803628 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 NORMANDIE DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361112732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342884624 | ||||||||
| FaxNumber: | 3342803628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | LAURENT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3342884624 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.