MEDICARE: WELLMART HEARTLAB INC

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		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W14K	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1245456219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLMART HEARTLAB INC

Provider Business Mailing Address
First Line	:	349 LAS COLINAS BLVD E
Second Line	:	SUITE C
City	:	IRVING
State	:	TX
Zip	:	75039-5557
Country	:	US
Telephone Number	:	972-739-2840
Fax Number	:	972-739-2854

Provider Business Practice Location Address
First Line	:	349 LAS COLINAS BLVD E
Second Line	:	SUITE C
City	:	IRVING
State	:	TX
Zip	:	75039-5557
Country	:	US
Telephone Number	:	972-739-2840
Fax Number	:	972-739-2854

Authorized Official
Title or Position	:	CEO
Name	:	JOHN DUNCAN
Credential	:
Telephone Number	:	972-739-2840

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	06/18/2008

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Directions to “WELLMART HEARTLAB INC ” Practice Location

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