Basic Information
| Provider Information | |||||||||
| NPI: | 1841283751 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMBERTON RADIOLOGICAL ASSOCIATES, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WELLNESS IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1527 | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283591527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388222 | ||||||||
| FaxNumber: | 9106710846 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 WEST 27TH STREET | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388222 | ||||||||
| FaxNumber: | 9106710846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GODWIN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | GROVER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9107388222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LUMBERTON RADIOLOGICAL ASSOCIATES, P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02037 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 5950357 | 05 | NC | MEDICAID | 8902037 | 05 | NC | MEDICAID |