MEDICARE: GENESIS MOBILE X-RAY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335V00000X	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R38642	OTHER	TX	DSHS

General Provider Information

NPI Number	:	1053737130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS MOBILE X-RAY, LLC

Provider Business Mailing Address
First Line	:	110 W RANDOL MILL RD
Second Line	:	STE 228
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4611
Country	:	US
Telephone Number	:	817-522-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 W RANDOL MILL RD
Second Line	:	STE 228
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4611
Country	:	US
Telephone Number	:	817-522-1002
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SARAH S NAVEED
Credential	:
Telephone Number	:	817-522-1002

Provider Enumeration Date	:	03/12/2014
Last Update Date	:	06/30/2017

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