Provider Demographics
NPI:1336271097
Name:TRAIL BLAZER DIAGNOSTICS
Entity type:Organization
Organization Name:TRAIL BLAZER DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-395-4121
Mailing Address - Street 1:1795 N FRY RD
Mailing Address - Street 2:#335
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-3347
Mailing Address - Country:US
Mailing Address - Phone:281-395-4121
Mailing Address - Fax:
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:#925
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:281-395-4121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile