Provider Demographics
NPI:1902090103
Name:ENHANCED MEDICAL IMAGING OF COOS BAY LLC
Entity Type:Organization
Organization Name:ENHANCED MEDICAL IMAGING OF COOS BAY LLC
Other - Org Name:SOUTH COAST RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WNUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-267-5411
Mailing Address - Street 1:2650 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2134
Mailing Address - Country:US
Mailing Address - Phone:541-267-5411
Mailing Address - Fax:541-267-4898
Practice Address - Street 1:2650 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2134
Practice Address - Country:US
Practice Address - Phone:541-267-5411
Practice Address - Fax:541-267-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory