Healthcare Provider Details

I. General information

NPI: 1700368222
Provider Name (Legal Business Name): BEXAR IMAGING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 NE LOOP 410 STE 121A
SAN ANTONIO TX
78216-5898
US

IV. Provider business mailing address

25 NE LOOP 410 STE 121A
SAN ANTONIO TX
78216-5898
US

V. Phone/Fax

Practice location:
  • Phone: 210-384-8439
  • Fax:
Mailing address:
  • Phone: 210-384-8439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRYAN D GRUNDHOEFER
Title or Position: MANAGER
Credential:
Phone: 210-617-4728