MEDICARE: IMAGIN ETC 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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center		TX

General Provider Information

NPI Number	:	1245525799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGIN ETC INC.

Provider Business Mailing Address
First Line	:	2507 MEDICAL ROW
Second Line	:	SUITE 102
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1070
Country	:	US
Telephone Number	:	214-688-8717
Fax Number	:	972-988-9807

Provider Business Practice Location Address
First Line	:	655 S GREAT SOUTHWEST PKWY
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1068
Country	:	US
Telephone Number	:	214-688-8717
Fax Number	:	972-988-9807

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	JACK GRAY JR.
Credential	:
Telephone Number	:	972-988-9800

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	06/13/2011

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