Independent Mobil Diagnostice Testing Facility

Primary specialty

Preferred Provider OrganizationTaxonomy code 305R00000X

License

22799 Issued in TX

Legal business name

INDEPENDENT MOBIL DIAGNOSTICE TESTING FACILITY

Practice address

1661 Woodard Ave
Suite 110
Cleburne, TX 76033-7052

Phone

(817) 494-6875

NPI assigned

Oct 12, 2011

Last updated

Oct 12, 2011By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Edmond S Maxon, LBSW

Title

Ed

Phone

(817) 494-6875

Specialties & licenses 2

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1318377600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1318377600000",
    "number": "1437434206",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1661 WOODARD AVE",
            "address_2": "SUITE 110",
            "city": "CLEBURNE",
            "state": "TX",
            "postal_code": "760337052",
            "telephone_number": "817-494-6875"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1661 WOODARD AVE",
            "address_2": "SUITE 110",
            "city": "CLEBURNE",
            "state": "TX",
            "postal_code": "760337052",
            "telephone_number": "817-494-6875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDEPENDENT MOBIL DIAGNOSTICE TESTING FACILITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-12",
        "last_updated": "2011-10-12",
        "status": "A",
        "authorized_official_last_name": "MAXON",
        "authorized_official_first_name": "EDMOND",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "ED",
        "authorized_official_telephone_number": "817-494-6875",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LBSW"
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "TX",
            "license": "22799",
            "primary": true
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "TX",
            "license": "22799",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Preferred Provider Organization in Cleburne, TX
• Providers in Cleburne, TX by specialty
• Preferred Provider Organization in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 12, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.