Provider Demographics
NPI:1124004148
Name:PHYSICIAN CARE & DIAGNOSTICS CENTER, LLC
Entity type:Organization
Organization Name:PHYSICIAN CARE & DIAGNOSTICS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-692-6560
Mailing Address - Street 1:PO BOX 420719
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77242-0719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3829 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-5814
Practice Address - Country:US
Practice Address - Phone:361-225-2624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0330DCOtherBC/BS OF TEXAS
TX160385401Medicaid
TX160385401Medicaid