1790781714 NPI number — MRI CENTRAL LUBBOCK LLC

Table of content: (NPI 1790781714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790781714 NPI number — MRI CENTRAL LUBBOCK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MRI CENTRAL LUBBOCK 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:
MRI CENTRAL LUBBOCK
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:
1790781714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12225 GREENVILLE AVE STE 700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-9338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-361-8018
Provider Business Mailing Address Fax Number:
888-542-6858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4511 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79413-3615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-281-0111
Provider Business Practice Location Address Fax Number:
806-788-0555
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
GARTH
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-368-9966

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , 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)

  • Identifier: 8685442 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2242044 . This is a "FIRST HEALTH CCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 362537100 . This is a "OWCP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7675373 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 152053801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2202558 . This is a "UHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0224DC . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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