=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598584203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BTDI JV, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2024
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 MARKETPLACE BLVD
-----------------------------------------------------
City | FORNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75126-6741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-954-8023
-----------------------------------------------------
Fax | 469-954-8024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 E MOREHEAD ST STE 300
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28202-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CREDENTIALING
-----------------------------------------------------
Name | KATRINA ROELLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-689-1691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------