Provider Demographics
NPI:1568408078
Name:COULTER IMAGING CENTER LLC
Entity Type:Organization
Organization Name:COULTER IMAGING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:TILDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-358-7149
Mailing Address - Street 1:PO BOX 50420
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79159-0420
Mailing Address - Country:US
Mailing Address - Phone:806-358-7149
Mailing Address - Fax:
Practice Address - Street 1:1900 COULTER ST
Practice Address - Street 2:UNIT N
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1782
Practice Address - Country:US
Practice Address - Phone:806-358-7149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR13716261QR0200X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
103168100OtherFIRSTCARE
TX080601001Medicaid
TX080601001Medicaid
TXFTXV01Medicare PIN