=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932634169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 3083 IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2017
-----------------------------------------------------
Last Update Date | 04/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1246 N FM 3083 WEST
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-922-6718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2257 N LOOP 336 W # 140368
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-922-6718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JULIE E MCKAY SMART
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 713-922-6718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------