MEDICARE: MOBILAB DIAGNOSTICS, 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	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1336408152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILAB DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	5904 S COOPER ST
Second Line	:	SUITE 104-184
City	:	ARLINGTON
State	:	TX
Zip	:	76017-4494
Country	:	US
Telephone Number	:	469-831-7111
Fax Number	:	888-557-1952

Provider Business Practice Location Address
First Line	:	5904 S COOPER ST
Second Line	:	SUITE 104-184
City	:	ARLINGTON
State	:	TX
Zip	:	76017-4494
Country	:	US
Telephone Number	:	469-831-7111
Fax Number	:	888-557-1952

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	DARRYL EVANS
Credential	:
Telephone Number	:	469-831-7111

Provider Enumeration Date	:	05/14/2012
Last Update Date	:	05/14/2012

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