Basic Information
| Provider Information | |||||||||
| NPI: | 1588647168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TWIN CREEKS RADIOLOGY L P | ||||||||
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| OtherOrganizationName: | ENVISION IMAGING OF ALLEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8610 EXPLORER DR | ||||||||
| Address2: | 300 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809201058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199554140 | ||||||||
| FaxNumber: | 7199554148 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 RAINTREE CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750134901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727478300 | ||||||||
| FaxNumber: | 9727479099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 11/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7199554332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 193698101 | 05 | TX | MEDICAID |