Provider Demographics
NPI:1821603580
Name:ORIGIN IMAGING & DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:ORIGIN IMAGING & DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-982-0845
Mailing Address - Street 1:PO BOX 6257
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-6257
Mailing Address - Country:US
Mailing Address - Phone:832-982-0845
Mailing Address - Fax:888-663-9778
Practice Address - Street 1:9135 KATY FWY STE 102
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1636
Practice Address - Country:US
Practice Address - Phone:832-655-4846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology