Provider Demographics
NPI:1851837124
Name:ABILENE IOM, LLC
Entity Type:Organization
Organization Name:ABILENE IOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-269-3875
Mailing Address - Street 1:111 BOLAND ST
Mailing Address - Street 2:211
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1263
Mailing Address - Country:US
Mailing Address - Phone:214-269-3875
Mailing Address - Fax:903-328-6568
Practice Address - Street 1:111 BOLAND ST
Practice Address - Street 2:211
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-1263
Practice Address - Country:US
Practice Address - Phone:214-269-3875
Practice Address - Fax:903-328-6568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-11
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty