Provider Demographics
NPI:1497930630
Name:ETHEL SHADE DBA SURE SHOT X-RAY MOBILE X-RAY SERVICES
Entity Type:Organization
Organization Name:ETHEL SHADE DBA SURE SHOT X-RAY MOBILE X-RAY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:972-822-9292
Mailing Address - Street 1:7310 S WESTMORELAND RD STE 11
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3015
Mailing Address - Country:US
Mailing Address - Phone:972-822-9292
Mailing Address - Fax:972-298-1137
Practice Address - Street 1:7310 S WESTMORELAND RD STE 11
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3015
Practice Address - Country:US
Practice Address - Phone:972-822-9292
Practice Address - Fax:972-298-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR31722261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR31722OtherRADIOLOGY
TXR31722OtherRADIOLOGY