Healthcare Provider Details

I. General information

NPI: 1104467232
Provider Name (Legal Business Name): INNATE IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7504 SAN JACINTO PL
PLANO TX
75024-3233
US

IV. Provider business mailing address

7504 SAN JACINTO PL
PLANO TX
75024-3233
US

V. Phone/Fax

Practice location:
  • Phone: 469-310-4977
  • Fax: 469-214-9981
Mailing address:
  • Phone: 469-310-4977
  • Fax: 469-214-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY D MARTIN JR.
Title or Position: PRESIDENT
Credential: DC
Phone: 469-215-3494