1285637017 NPI number — SOUTHWEST IMAGING CENTER INC

Table of content: (NPI 1285637017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285637017 NPI number — SOUTHWEST IMAGING CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST IMAGING CENTER INC
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:
THE IMAGING CENTER
Provider Other Organization Name Type Code:
4
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:
1285637017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5116 W GORE BLVD
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73505-5909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-353-7226
Provider Business Mailing Address Fax Number:
580-353-7297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5116 W GORE BLVD
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-5909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-353-7226
Provider Business Practice Location Address Fax Number:
580-353-7297
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KETCHER
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
BILLING OFFICE MANAGAER
Authorized Official Telephone Number:
580-353-7226

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  700560 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100744930A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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