MEDICARE: WASHINGTON AVE DIAGNOSTIC CENTER

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	111N00000X	Chiropractor	10580	TX
2	261Q00000X	Clinic/Center	0J63X	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568573525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON AVE DIAGNOSTIC CENTER

Provider Business Mailing Address
First Line	:	2510 WASHINGTON AVE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-6021
Country	:	US
Telephone Number	:	713-802-9188
Fax Number	:	713-802-2278

Provider Business Practice Location Address
First Line	:	2510 WASHINGTON AVE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-6021
Country	:	US
Telephone Number	:	713-802-9188
Fax Number	:	713-802-2278

Authorized Official
Title or Position	:	ADM
Name	:	MR. JAIME BONILLA
Credential	:
Telephone Number	:	713-802-9188

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	06/03/2009

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Directions to “WASHINGTON AVE DIAGNOSTIC CENTER ” Practice Location

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