Provider Demographics
NPI:1588759849
Name:EXECUTIVE IMAGE INC
Entity type:Organization
Organization Name:EXECUTIVE IMAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-918-6328
Mailing Address - Street 1:7820 N POINT BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3299
Mailing Address - Country:US
Mailing Address - Phone:336-245-0647
Mailing Address - Fax:336-245-0649
Practice Address - Street 1:7820 N POINT BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3299
Practice Address - Country:US
Practice Address - Phone:336-245-0647
Practice Address - Fax:336-245-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC600495328335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00245445OtherMEDICARE RAILROAD
NC3409805Medicaid
NCP00245445OtherMEDICARE RAILROAD
NC3409805Medicaid