Healthcare Provider Details

I. General information

NPI: 1518367697
Provider Name (Legal Business Name): CONSTANCE BROADHURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9441 LBJ FWY SUITE 602
DALLAS TX
75243-4545
US

IV. Provider business mailing address

9441 LBJ FWY SUITE 602
DALLAS TX
75243-4545
US

V. Phone/Fax

Practice location:
  • Phone: 469-249-1887
  • Fax:
Mailing address:
  • Phone: 469-249-1887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number171300
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: