Provider Demographics
NPI:1891717799
Name:WICHITA AREA MOBILE SERVICE
Entity Type:Organization
Organization Name:WICHITA AREA MOBILE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:FANCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-761-2882
Mailing Address - Street 1:2113 KELL BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1256
Mailing Address - Country:US
Mailing Address - Phone:940-761-2882
Mailing Address - Fax:
Practice Address - Street 1:2113 KELL BLVD STE E
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1256
Practice Address - Country:US
Practice Address - Phone:940-761-2882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45-X0009901335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45X0009901OtherPORT. XRAY MCR ID NO.
MI7102000TX76308OtherBCBS OF MICHIGAN
TX178472001Medicaid
00000MDXOOtherBCBS OF TEXAS
TX000009998OtherBCBS OF TEXAS PROVIDER NO
TX178472001Medicaid
00000MDXOOtherBCBS OF TEXAS
TXASC272Medicare ID - Type UnspecifiedMEDICARE TRAILBLAZER NO.