Basic Information
| Provider Information | |||||||||
| NPI: | 1770182933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE PET SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 ASHEVILL AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27618 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 ASHVILLE AVENUE | ||||||||
| Address2: | SUITE 100A | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | SESSOMS | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9193500522 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.