Provider Demographics
NPI:1770508624
Name:MID-COUNTY OPEN MRI
Entity Type:Organization
Organization Name:MID-COUNTY OPEN MRI
Other - Org Name:BRAZOS VALLEY OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEYVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-268-6749
Mailing Address - Street 1:4301 CARTER CREEK PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-4485
Mailing Address - Country:US
Mailing Address - Phone:979-268-6749
Mailing Address - Fax:
Practice Address - Street 1:4301 CARTER CREEK PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-4485
Practice Address - Country:US
Practice Address - Phone:979-268-6749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FTX086Medicare ID - Type Unspecified