Provider Demographics
NPI:1982069332
Name:DYNAMIC DIAGNOSTIC LLC
Entity Type:Organization
Organization Name:DYNAMIC DIAGNOSTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIETEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-310-8119
Mailing Address - Street 1:455 JULIE RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 JULIE RIVERS DR
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3146
Practice Address - Country:US
Practice Address - Phone:281-240-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile