Provider Demographics
NPI:1558523357
Name:GRACE CLINIC IMAGING DEPARTMENT
Entity Type:Organization
Organization Name:GRACE CLINIC IMAGING DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-740-3342
Mailing Address - Street 1:2804 N LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415-1410
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:4515 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2520
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR306822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0608DCOtherBCBS OUTSIDE IMAGING
TX0031NROtherBCBS GROUP NO.