Provider Demographics
NPI:1396163507
Name:ELITE DIAGNOSTIC IMAGING
Entity type:Organization
Organization Name:ELITE DIAGNOSTIC IMAGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ARLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:713-239-2810
Mailing Address - Street 1:2500 E TC JESTER BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-1365
Mailing Address - Country:US
Mailing Address - Phone:713-239-2810
Mailing Address - Fax:
Practice Address - Street 1:2500 E TC JESTER BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1365
Practice Address - Country:US
Practice Address - Phone:713-239-2810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELITE SURGEONS MSO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)