=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770695819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGE AMERICA DIAGNOSTIC IMAGING CENTER, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3391 WESTPARK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-4262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-8383
-----------------------------------------------------
Fax | 713-663-6262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3391 WESTPARK DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-4262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-8383
-----------------------------------------------------
Fax | 713-663-6262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BRIAN DAVID MOBLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-660-8383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------