=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821937368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUME DIAGNOSTIC IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2026
-----------------------------------------------------
Last Update Date | 03/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 8TH AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76110-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-233-3505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6514 FANNIN FARM WAY
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76001-5802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-233-3505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SPECIALIST
-----------------------------------------------------
Name | RENUKA SHAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-455-5755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247100000X
-----------------------------------------------------
Taxonomy Name | Radiologic Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------