MEDICARE: KMA DIAGNOSTIC 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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1922412584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMA DIAGNOSTIC LLC

Provider Business Mailing Address
First Line	:	10330 LAKE RD STE M
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-1886
Country	:	US
Telephone Number	:	713-960-4461
Fax Number	:

Provider Business Practice Location Address
First Line	:	10330 LAKE RD STE M
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-1886
Country	:	US
Telephone Number	:	713-960-4461
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	MRS. ROSALIND W CIESLEWICZ
Credential	:
Telephone Number	:	713-960-4461

Provider Enumeration Date	:	06/11/2014
Last Update Date	:	06/11/2014

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