Provider Demographics
NPI:1417600412
Name:BREAST IMAGING OF THE OZARKS LLC
Entity type:Organization
Organization Name:BREAST IMAGING OF THE OZARKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:870-945-9455
Mailing Address - Street 1:3206 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5143
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:903-663-9960
Practice Address - Street 1:2144 E REPUBLIC RD STE 104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4623
Practice Address - Country:US
Practice Address - Phone:870-945-9455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty