=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811646680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZOOM DIAGNOSTIC IMAGING PONCA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2022
-----------------------------------------------------
Last Update Date | 03/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1119 W CHERRY AVE
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73703-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-540-3270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3508 SOUTHWESTERN BLVD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75225-7454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-504-6156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID SAVAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-504-6156
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------