Provider Demographics
NPI:1366203655
Name:PANHANDLE DIAGNOSTICS LLC
Entity type:Organization
Organization Name:PANHANDLE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS/RVT
Authorized Official - Phone:850-398-0108
Mailing Address - Street 1:5736 GRIFFITH CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:FL
Mailing Address - Zip Code:32531-8402
Mailing Address - Country:US
Mailing Address - Phone:850-401-2418
Mailing Address - Fax:
Practice Address - Street 1:502 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-4250
Practice Address - Country:US
Practice Address - Phone:850-401-2418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty