Provider Demographics
NPI:1396850632
Name:COMMUNITY PORTABLE X-RAY, LLC
Entity Type:Organization
Organization Name:COMMUNITY PORTABLE X-RAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-371-0073
Mailing Address - Street 1:PO BOX 39931
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239-0931
Mailing Address - Country:US
Mailing Address - Phone:303-371-0073
Mailing Address - Fax:303-576-7986
Practice Address - Street 1:1635 DORCHESTER DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6443
Practice Address - Country:US
Practice Address - Phone:972-633-9427
Practice Address - Fax:972-881-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143330202Medicaid
TXFTA145Medicare PIN
TX459886Medicare PIN