MEDICARE: CCK DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1558941930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCK DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	2757 AIRPORT FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-2333
Country	:	US
Telephone Number	:	682-707-5474
Fax Number	:	682-213-8889

Provider Business Practice Location Address
First Line	:	2757 AIRPORT FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-2333
Country	:	US
Telephone Number	:	682-707-5474
Fax Number	:	682-213-8889

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	CARL WANG
Credential	:
Telephone Number	:	682-707-5474

Provider Enumeration Date	:	04/10/2021
Last Update Date	:	04/24/2021

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