Healthcare Provider Details

I. General information

NPI: 1558483776
Provider Name (Legal Business Name): BMB ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2698 N GALLOWAY AVE
MESQUITE TX
75150-6383
US

IV. Provider business mailing address

2698 N GALLOWAY AVE
MESQUITE TX
75150-6383
US

V. Phone/Fax

Practice location:
  • Phone: 972-681-4000
  • Fax: 972-681-0881
Mailing address:
  • Phone: 972-681-4000
  • Fax: 972-681-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberR31261
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License NumberR31261
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberR31261
License Number StateTX

VIII. Authorized Official

Name: MR. MINU MAMMEN MATHEW
Title or Position: DIRECTOR
Credential: R, MR, ARRT
Phone: 972-681-4000