Provider Demographics
NPI:1861806283
Name:PRESTIGE DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:PRESTIGE DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-887-9750
Mailing Address - Street 1:6491 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2777
Mailing Address - Country:US
Mailing Address - Phone:817-887-9750
Mailing Address - Fax:817-887-9753
Practice Address - Street 1:6491 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76132-2777
Practice Address - Country:US
Practice Address - Phone:817-887-9750
Practice Address - Fax:817-887-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP00343899261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology