Provider Demographics
NPI:1134559800
Name:PRESTIGE CARDIOPULMONARY DIAGNOSTIC SERVICES, LLC
Entity type:Organization
Organization Name:PRESTIGE CARDIOPULMONARY DIAGNOSTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEWCOMER
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:252-621-1052
Mailing Address - Street 1:508 E MAIN ST STE 209
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4458
Mailing Address - Country:US
Mailing Address - Phone:252-621-1052
Mailing Address - Fax:
Practice Address - Street 1:508 E MAIN ST STE 209
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4458
Practice Address - Country:US
Practice Address - Phone:252-621-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9558523261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center