Provider Demographics
NPI:1154784205
Name:MED VENTURES MRI, LLC
Entity type:Organization
Organization Name:MED VENTURES MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOLLSTROM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:706-594-0687
Mailing Address - Street 1:1975 HWY 54 W.
Mailing Address - Street 2:STE 205
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4794
Mailing Address - Country:US
Mailing Address - Phone:678-561-9000
Mailing Address - Fax:770-487-1232
Practice Address - Street 1:1075 LAFAYETTE PARKWAY
Practice Address - Street 2:STE 120
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241
Practice Address - Country:US
Practice Address - Phone:706-845-9370
Practice Address - Fax:706-845-9371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty