Provider Demographics
NPI:1124294194
Name:WEST STANLY IMAGING LLC
Entity type:Organization
Organization Name:WEST STANLY IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-984-4393
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28002-0686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 STANLY PKWY
Practice Address - Street 2:SUITE E
Practice Address - City:LOCUST
Practice Address - State:NC
Practice Address - Zip Code:28097-7704
Practice Address - Country:US
Practice Address - Phone:704-781-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8105034Medicaid
NC020XFOtherBCBS OF NORTH
P00670112OtherRAILROAD MEDICARE
NC8105034Medicaid