Basic Information
| Provider Information | |||||||||
| NPI: | 1518040369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREFERRED IMAGING OF GRAPEVINE/COLLEYVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268945 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 W NORTHWEST HWY | ||||||||
| Address2: | STE. 1000 | ||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760518112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174216285 | ||||||||
| FaxNumber: | 8178862537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | KASSA | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9045150362 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 283281802 | 05 | TX | MEDICAID |