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General NPI Number Information
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NPI Number | 1578214284
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Entity Type | Organization
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Legal Business Name | MEDIVEST DENTON, LP
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Dates
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Enumeration Date | 01/13/2022
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Last Update Date | 12/27/2024
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Provider Practice Location Address
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Address Line | 1713 S FM 51 # 104
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City | DECATUR
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State | TX
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Zip | 76234-3642
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Country | US
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Telephone | 817-377-3800
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Fax | 817-377-3801
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Provider Business Mailing Address
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Address Line | 3712 W 7TH ST
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City | FORT WORTH
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State | TX
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Zip | 76107-2536
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Country | US
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Telephone | 817-202-5179
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Fax | 817-377-3801
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | CHELSEA MECHELLE HOLDER
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Credential |
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Telephone | 817-377-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 293D00000X
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Taxonomy Name | Physiological Laboratory
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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