Provider Demographics
NPI:1659622629
Name:VILLAGE DIAGNOSTIC CLINIC, INC.
Entity Type:Organization
Organization Name:VILLAGE DIAGNOSTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAKHMANOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-830-8574
Mailing Address - Street 1:10101 HARWIN DR
Mailing Address - Street 2:SUITE # 194
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-1687
Mailing Address - Country:US
Mailing Address - Phone:832-830-8574
Mailing Address - Fax:832-830-8659
Practice Address - Street 1:10101 HARWIN DR
Practice Address - Street 2:SUITE # 194
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-1687
Practice Address - Country:US
Practice Address - Phone:832-830-8574
Practice Address - Fax:832-830-8659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty