=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982639977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS MRI LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 03/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8806 N NAVARRO ST SUITE 100
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77904-1556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-485-9400
-----------------------------------------------------
Fax | 361-485-9933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8806 N NAVARRO ST SUITE 100
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77904-1556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-485-9400
-----------------------------------------------------
Fax | 361-485-9933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING/MARKETING COORDINATOR
-----------------------------------------------------
Name | MRS. VICKI A WAGNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 361-485-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------