MEDICARE: PRIMARY PINNACLE 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1972014116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY PINNACLE DIAGNOSTIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 1138
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-0018
Country	:	US
Telephone Number	:	972-665-9930
Fax Number	:	214-261-5155

Provider Business Practice Location Address
First Line	:	1903 CENTRAL DR STE 215
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76021-5876
Country	:	US
Telephone Number	:	817-786-8991
Fax Number	:	214-261-5155

Authorized Official
Title or Position	:	VP REVENUE CYCLE
Name	:	RONNA BROOKS
Credential	:
Telephone Number	:	972-665-9930

Provider Enumeration Date	:	10/16/2017
Last Update Date	:	10/19/2017

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