Provider Demographics
NPI:1861528747
Name:MMDS OF KINGSPORT LLC
Entity type:Organization
Organization Name:MMDS OF KINGSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-230-8093
Mailing Address - Street 1:1038 S WILCOX DR
Mailing Address - Street 2:SUITE # AA
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5378
Mailing Address - Country:US
Mailing Address - Phone:423-230-8093
Mailing Address - Fax:423-230-4932
Practice Address - Street 1:367 NATURES WAY DR
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-5153
Practice Address - Country:US
Practice Address - Phone:423-230-8093
Practice Address - Fax:423-230-4932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MMDS OF KINGSPORT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192949770Medicare PIN