1972512994 NPI number — INNERFACE IMAGING LLC

Table of content: GAIL ELIZABETH WYATT PHD (NPI 1700994498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972512994 NPI number — INNERFACE IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNERFACE IMAGING LLC
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:
Provider Other Organization Name Type Code:
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:
1972512994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4630 EUBANK BLVD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-323-9906
Provider Business Mailing Address Fax Number:
505-298-7227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10100 N CENTRAL EXPRESSWAY
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-346-9129
Provider Business Practice Location Address Fax Number:
214-346-1983
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FICHTNER
Authorized Official First Name:
E
Authorized Official Middle Name:
GARY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-314-1669

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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