MEDICARE: ELITE VIEW IMAGING, 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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1144684200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE VIEW IMAGING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 857
Second Line	:	SUITE 100
City	:	COPPELL
State	:	TX
Zip	:	75019-0857
Country	:	US
Telephone Number	:	972-315-0362
Fax Number	:	972-906-9631

Provider Business Practice Location Address
First Line	:	750 12TH AVE
Second Line	:	SUITE 100
City	:	FT WORTH
State	:	TX
Zip	:	76104-2531
Country	:	US
Telephone Number	:	817-877-3054
Fax Number	:	817-546-0851

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE
Name	:	ANGELA MALLETT
Credential	:
Telephone Number	:	972-315-0362

Provider Enumeration Date	:	04/05/2016
Last Update Date	:	04/05/2016

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