Provider Demographics
NPI:1104889377
Name:INMED DIAGNOSTICS SERVICES OF SC LLC
Entity type:Organization
Organization Name:INMED DIAGNOSTICS SERVICES OF SC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE & CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTIVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-241-6100
Mailing Address - Street 1:PO BOX 593869
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32859-3869
Mailing Address - Country:US
Mailing Address - Phone:352-241-6100
Mailing Address - Fax:352-241-6101
Practice Address - Street 1:126 S ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-4545
Practice Address - Country:US
Practice Address - Phone:803-988-0082
Practice Address - Fax:803-988-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X
SC19347261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPL0036Medicaid
SCPL0036Medicaid