=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548095920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREFERRED DIAGNOSTIC IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2419 N COMMERCE ST STE C
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-226-7587
-----------------------------------------------------
Fax | 580-226-4878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 LILAC DR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-7297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-906-3375
-----------------------------------------------------
Fax | 405-216-3743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. BENT KEITH HOLLIMAN
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 405-227-1280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------