Provider Demographics
NPI:1780021956
Name:IMAGING CENTER OF MAGNOLIA PLLC
Entity Type:Organization
Organization Name:IMAGING CENTER OF MAGNOLIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOTSIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-296-9562
Mailing Address - Street 1:4185 TECHNOLOGY FOREST BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-2006
Mailing Address - Country:US
Mailing Address - Phone:281-296-9562
Mailing Address - Fax:281-296-9774
Practice Address - Street 1:827 MAGNOLIA BLVD STE 2
Practice Address - Street 2:SUITE B
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77355-8553
Practice Address - Country:US
Practice Address - Phone:281-789-4329
Practice Address - Fax:281-789-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty