=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538341110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2007
-----------------------------------------------------
Last Update Date | 12/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 S LANCASTER RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75216-7167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-857-6589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10224 IRONWOOD LN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75249-1538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-857-6589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RADIOLOGIC TECHNOLOGIST
-----------------------------------------------------
Name | ANGELA WALL
-----------------------------------------------------
Credential | RTR
-----------------------------------------------------
Telephone | 214-857-6589
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | 26548
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------