=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740814029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VENUS MRI & WOMEN'S CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2020
-----------------------------------------------------
Last Update Date | 05/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24721 TOMBALL PKWY STE 150
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-7727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-336-7700
-----------------------------------------------------
Fax | 832-205-0339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2255 E MOSSY OAKS RD STE 500
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77389-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-336-7700
-----------------------------------------------------
Fax | 832-294-9822
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | DR. DAVID ELLENT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 346-336-7700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------