Provider Demographics
NPI:1639203284
Name:MED TEL INTERANTIONAL CORPORATION
Entity Type:Organization
Organization Name:MED TEL INTERANTIONAL CORPORATION
Other - Org Name:WIDE OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-873-9850
Mailing Address - Street 1:1430 SPRING HILL RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3000
Mailing Address - Country:US
Mailing Address - Phone:703-287-4189
Mailing Address - Fax:703-448-1807
Practice Address - Street 1:1515 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4404
Practice Address - Country:US
Practice Address - Phone:940-766-5242
Practice Address - Fax:940-766-0449
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED TEL INTERNATIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163697901Medicaid
TX163697901Medicaid