Provider Demographics
NPI:1922343342
Name:BOULEVARD DIAGNOSTIC MGMT GROUP
Entity Type:Organization
Organization Name:BOULEVARD DIAGNOSTIC MGMT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-741-0808
Mailing Address - Street 1:3120 W SOUTHLAKE BLVD # 140
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3120 W SOUTHLAKE BLVD # 140
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6783
Practice Address - Country:US
Practice Address - Phone:817-741-0808
Practice Address - Fax:817-741-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology