Basic Information
| Provider Information | |||||||||
| NPI: | 1346346954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXECUTOR DIAGNOSTICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1929A MOUNTAIN LAUREL CT | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295056053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1929 MOUNTAIN LAUREL CT # A | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295056053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432921112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCINVILLE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS SERVICE REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 8436695162 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | SC | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | L00218 | 05 | SC | MEDICAID |