Basic Information
Provider Information
NPI: 1033796388
EntityType: 2
ReplacementNPI:  
OrganizationName: ADVANCED X-PRESS X-RAY, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1911 BAGBY ST
Address2:  
City: HOUSTON
State: TX
PostalCode: 770028594
CountryCode: US
TelephoneNumber: 7137901666
FaxNumber: 7133834446
Practice Location
Address1: 1911 BAGBY ST
Address2:  
City: HOUSTON
State: TX
PostalCode: 770028594
CountryCode: US
TelephoneNumber: 7137901666
FaxNumber: 7133834446
Other Information
ProviderEnumerationDate: 03/24/2021
LastUpdateDate: 03/24/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GUIDRY
AuthorizedOfficialFirstName: LANISA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: REVENUE CYCLE VICE PRESIDENT
AuthorizedOfficialTelephone: 7137951107
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/24/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
335V00000X  Y SuppliersPortable X-Ray Supplier 

ID Information
IDTypeStateIssuerDescription
R4708301TXST LICENSEOTHER


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