=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831757087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AE DIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23818 HIGHWAY 59 N
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-3954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-358-3800
-----------------------------------------------------
Fax | 281-358-3910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9802 FM 1960 BYPASS RD W STE 100
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-3572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-358-3800
-----------------------------------------------------
Fax | 281-358-3910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | GRACIE DELEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-358-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------