Provider Demographics
NPI:1871507657
Name:TELEVYDE, LLC
Entity Type:Organization
Organization Name:TELEVYDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-774-4563
Mailing Address - Street 1:3201 UNIVERSITY DR E STE 325
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3478
Mailing Address - Country:US
Mailing Address - Phone:979-774-4563
Mailing Address - Fax:979-774-4546
Practice Address - Street 1:3201 UNIVERSITY DR E STE 325
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3478
Practice Address - Country:US
Practice Address - Phone:979-774-4563
Practice Address - Fax:979-774-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR29053261QM1200X
261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161716901Medicaid
TX161716901Medicaid