Provider Demographics
NPI:1316075179
Name:KING'S MEDICAL IMAGING AT WATERMARK, LLC
Entity type:Organization
Organization Name:KING'S MEDICAL IMAGING AT WATERMARK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEATTIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-653-3689
Mailing Address - Street 1:5339 HENDRON RD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-1055
Mailing Address - Country:US
Mailing Address - Phone:614-835-0358
Mailing Address - Fax:614-835-0712
Practice Address - Street 1:5339 HENDRON RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-1055
Practice Address - Country:US
Practice Address - Phone:614-835-0358
Practice Address - Fax:614-835-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHID01422Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID