Provider Demographics
NPI:1376629329
Name:ENTERRA MEDICAL DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:ENTERRA MEDICAL DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KALUARACHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-467-7434
Mailing Address - Street 1:5787 S HAMPTON RD
Mailing Address - Street 2:STE 450
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-2255
Mailing Address - Country:US
Mailing Address - Phone:214-467-7434
Mailing Address - Fax:214-467-7434
Practice Address - Street 1:5787 S HAMPTON RD
Practice Address - Street 2:STE 255
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-2255
Practice Address - Country:US
Practice Address - Phone:214-330-7030
Practice Address - Fax:214-330-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0076258332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179148501Medicaid
TX179148502Medicaid
TX179148502Medicaid