Healthcare Provider Details

I. General information

NPI: 1639041759
Provider Name (Legal Business Name): YOUR SCAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 E PIONEER PKWY STE A
ARLINGTON TX
76010-6411
US

IV. Provider business mailing address

1334 E PIONEER PKWY STE A
ARLINGTON TX
76010-6411
US

V. Phone/Fax

Practice location:
  • Phone: 817-705-8005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name: VIAN BOUTALOTH
Title or Position: CEO
Credential:
Phone: 817-705-8005