Healthcare Provider Details

I. General information

NPI: 1972084432
Provider Name (Legal Business Name): MOPAC IMAGING, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3742 FAR WEST BLVD STE 109
AUSTIN TX
78731-3044
US

IV. Provider business mailing address

3742 FAR WEST BLVD STE 109
AUSTIN TX
78731-3044
US

V. Phone/Fax

Practice location:
  • Phone: 512-372-1062
  • Fax: 512-372-1064
Mailing address:
  • Phone: 512-372-1062
  • Fax: 512-372-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH LAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 210-660-3001