Provider Demographics
NPI:1477664803
Name:SONOGRAPHIC IMAGING SERVICES
Entity Type:Organization
Organization Name:SONOGRAPHIC IMAGING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:RVT, RT, LVN
Authorized Official - Phone:936-336-3616
Mailing Address - Street 1:PO BOX 222
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:TX
Mailing Address - Zip Code:77575-0222
Mailing Address - Country:US
Mailing Address - Phone:936-336-3616
Mailing Address - Fax:
Practice Address - Street 1:2718A N MAIN ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3909
Practice Address - Country:US
Practice Address - Phone:936-336-3616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1152782471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPL0308OtherBCBS PROVIDER NUMBER
TXPL0308OtherBCBS PROVIDER NUMBER