Provider Demographics
NPI:1053327635
Name:BROAD HORIZON IMAGING, INC.
Entity Type:Organization
Organization Name:BROAD HORIZON IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-864-9932
Mailing Address - Street 1:1205 N BEDELL AVE
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4163
Practice Address - Country:US
Practice Address - Phone:830-775-9563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00850VMedicare PIN