MEDICARE: PRESTIGE 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	:	1407014467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE IMAGING LLC

Provider Business Mailing Address
First Line	:	6301 ABRAMS RD STE 131
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-7856
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 WABASH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6528
Country	:	US
Telephone Number	:	817-992-9989
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	BRAD SCOBLE
Credential	:
Telephone Number	:	817-992-9989

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	06/24/2008

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