Provider Demographics
NPI:1164608923
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:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-558-1940
Mailing Address - Street 1:6301 ABRAMS RD
Mailing Address - Street 2:SUITE 131B
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-7818
Mailing Address - Country:US
Mailing Address - Phone:469-916-8894
Mailing Address - Fax:
Practice Address - Street 1:2901 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-1803
Practice Address - Country:US
Practice Address - Phone:903-663-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTX246Medicare PIN