Provider Demographics
NPI:1083642656
Name:PRESTIGE IMAGING, LLC
Entity Type:Organization
Organization Name:PRESTIGE IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-558-1940
Mailing Address - Street 1:2916 N SAM RAYBURN FWY
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-2546
Mailing Address - Country:US
Mailing Address - Phone:903-868-2255
Mailing Address - Fax:903-868-8011
Practice Address - Street 1:2916 N SAM RAYBURN FWY
Practice Address - Street 2:SUITE 610
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-2546
Practice Address - Country:US
Practice Address - Phone:903-868-2255
Practice Address - Fax:903-868-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR29470261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00305755OtherMEDICARE RAIL ROAD
TXP00305755OtherMEDICARE RAIL ROAD