Provider Demographics
NPI:1710983424
Name:WESTSIDE OPEN MRI DIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:WESTSIDE OPEN MRI DIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-252-4363
Mailing Address - Street 1:301 N SHACKLEFORD RD
Mailing Address - Street 2:STE B4
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2882
Mailing Address - Country:US
Mailing Address - Phone:501-312-9990
Mailing Address - Fax:501-312-9991
Practice Address - Street 1:301 N SHACKLEFORD RD
Practice Address - Street 2:STE B4
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2882
Practice Address - Country:US
Practice Address - Phone:501-312-9990
Practice Address - Fax:501-312-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139137002Medicaid
5C257Medicare ID - Type Unspecified