Provider Demographics
NPI:1417114380
Name:ENNIS DIAGNOSTIC CENTER, INC.
Entity Type:Organization
Organization Name:ENNIS DIAGNOSTIC CENTER, INC.
Other - Org Name:ELITE MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-587-3760
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75120-0086
Mailing Address - Country:US
Mailing Address - Phone:972-875-6961
Mailing Address - Fax:
Practice Address - Street 1:104 S DALLAS ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4745
Practice Address - Country:US
Practice Address - Phone:972-875-6961
Practice Address - Fax:972-875-8046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0104673332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2004095Medicaid
TX2004095Medicaid