1770610685 NPI number — MID-CITIES IMAGING, L.P.

Table of content: DR. ANDREW RICHARD VANCLEVE DPH (NPI 1336350719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770610685 NPI number — MID-CITIES IMAGING, L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-CITIES IMAGING, L.P.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MID CITIES IMAGING, RANDOL MILL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770610685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 835885
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHARDSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75083-5885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-498-1963
Provider Business Mailing Address Fax Number:
972-498-1965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 W RANDOL MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76012-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-701-1306
Provider Business Practice Location Address Fax Number:
682-367-1770
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ARCHER
Authorized Official First Name:
ARDELLE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
972-498-1963

Provider Taxonomy Codes

  • Taxonomy code: 2471M1202X , with the licence number:  R30811 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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