Provider Demographics
NPI:1588942148
Name:ST. ELIZABETH IMAGING CENTER, LLC
Entity type:Organization
Organization Name:ST. ELIZABETH IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-924-2424
Mailing Address - Street 1:17609 OLD JEFFERSON HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3979
Mailing Address - Country:US
Mailing Address - Phone:225-924-2424
Mailing Address - Fax:225-408-7843
Practice Address - Street 1:17609 OLD JEFFERSON HWY
Practice Address - Street 2:SUITE A
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3979
Practice Address - Country:US
Practice Address - Phone:225-924-2424
Practice Address - Fax:225-408-7843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology