Provider Demographics
NPI:1215158548
Name:DMX IMAGING OF ANDERSON
Entity type:Organization
Organization Name:DMX IMAGING OF ANDERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DC
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WICKISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-224-0283
Mailing Address - Street 1:3618 E RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-7334
Mailing Address - Country:US
Mailing Address - Phone:864-224-0283
Mailing Address - Fax:
Practice Address - Street 1:3618 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7334
Practice Address - Country:US
Practice Address - Phone:864-224-0283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI645111NR0400X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2599Medicaid
SCGCH104Medicaid
SCGCH104Medicaid
SCCH2599Medicaid