MEDICARE: TRAIL BLAZER DIAGNOSTICS

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	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1336271097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAIL BLAZER DIAGNOSTICS

Provider Business Mailing Address
First Line	:	1795 N FRY RD
Second Line	:	#335
City	:	KATY
State	:	TX
Zip	:	77449-3347
Country	:	US
Telephone Number	:	281-395-4121
Fax Number	:

Provider Business Practice Location Address
First Line	:	221 W COLORADO BLVD
Second Line	:	#925
City	:	DALLAS
State	:	TX
Zip	:	75208-2363
Country	:	US
Telephone Number	:	281-395-4121
Fax Number	:

Authorized Official
Title or Position	:	V.P. OF OPERATIONS
Name	:	MR. SHARON MARTIN
Credential	:
Telephone Number	:	281-395-4121

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	08/22/2020

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Directions to “TRAIL BLAZER DIAGNOSTICS ” Practice Location

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