Healthcare Provider Details

I. General information

NPI: 1376914218
Provider Name (Legal Business Name): BLUESCRUBS DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 SPRING VALLEY RD STE 632
DALLAS TX
75244-3629
US

IV. Provider business mailing address

4100 SPRING VALLEY RD STE 632
DALLAS TX
75244-3629
US

V. Phone/Fax

Practice location:
  • Phone: 972-220-8619
  • Fax:
Mailing address:
  • Phone: 972-220-8619
  • Fax: 972-421-1674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. JERMAINE ANDRE WADE
Title or Position: PRESIDENT
Credential:
Phone: 972-220-8619