Healthcare Provider Details

I. General information

NPI: 1962182584
Provider Name (Legal Business Name): ELITE DIAGNOSTIC IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 WARREN PKWY STE 102
FRISCO TX
75034-4166
US

IV. Provider business mailing address

5616 WARREN PKWY STE 102
FRISCO TX
75034-4166
US

V. Phone/Fax

Practice location:
  • Phone: 214-762-9084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN IPPOLITO
Title or Position: MANAGER
Credential:
Phone: 214-228-0701