=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598718835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E PET IMAGING XVII, L.P.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6021 FAIRMONT PKWY SUITE 120
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77505-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-991-4615
-----------------------------------------------------
Fax | 281-991-4611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6021 FAIRMONT PKWY SUITE 120
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77505-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-991-4615
-----------------------------------------------------
Fax | 281-991-4611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY OF GENERAL PARTNER
-----------------------------------------------------
Name | JERRY EYLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-467-7408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------