Healthcare Provider Details

I. General information

NPI: 1578331393
Provider Name (Legal Business Name): CLINICAL CARE IN RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 8TH AVE STE 120
FORT WORTH TX
76104-4155
US

IV. Provider business mailing address

816 W CANNON ST
FORT WORTH TX
76104-3146
US

V. Phone/Fax

Practice location:
  • Phone: 817-321-0404
  • Fax:
Mailing address:
  • Phone: 817-321-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: RACHEL MAITLAND
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 817-321-0937