Provider Demographics
NPI:1104993526
Name:DIAGNOSTIC CLINIC P C
Entity type:Organization
Organization Name:DIAGNOSTIC CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:VANCLEAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-880-8828
Mailing Address - Street 1:185 WHITESPORT DR SW
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6486
Mailing Address - Country:US
Mailing Address - Phone:256-880-8828
Mailing Address - Fax:256-880-8756
Practice Address - Street 1:185 WHITESPORT DR SW
Practice Address - Street 2:SUITE 1
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6486
Practice Address - Country:US
Practice Address - Phone:256-880-8828
Practice Address - Fax:256-880-8756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14493261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD79349Medicare UPIN
ALC71739Medicare UPIN