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General NPI Number Information
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NPI Number | 1356341184
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Entity Type | Organization
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Legal Business Name | PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
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Dates
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Enumeration Date | 07/22/2005
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Last Update Date | 04/04/2022
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Provider Practice Location Address
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Address Line | 1665 ANTILLEY RD SUITE 200
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City | ABILENE
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State | TX
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Zip | 79606-5265
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Country | US
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Telephone | 325-437-8655
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Fax | 325-437-8647
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Provider Business Mailing Address
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Address Line | PO BOX 5409
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City | ABILENE
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State | TX
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Zip | 79608-5409
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Country | US
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Telephone | 325-437-8655
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Fax | 325-437-8647
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Authorized Official
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Title or Position | CEO/AUTHORIZED OFFICIAL
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Name | ANDREW KOUBA
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Credential |
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Telephone | 325-437-8645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471C3402X
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Taxonomy Name | Radiography Radiologic Technologist
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License Number | R2280
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License Number State | TX
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