Provider Demographics
NPI:1437434206
Name:INDEPENDENT MOBIL DIAGNOSTICE TESTING FACILITY
Entity Type:Organization
Organization Name:INDEPENDENT MOBIL DIAGNOSTICE TESTING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ED
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAXON
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:817-494-6875
Mailing Address - Street 1:1661 WOODARD AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-7052
Mailing Address - Country:US
Mailing Address - Phone:817-494-6875
Mailing Address - Fax:
Practice Address - Street 1:1661 WOODARD AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7052
Practice Address - Country:US
Practice Address - Phone:817-494-6875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22799305R00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities