Organization
INDEPENDENT MOBIL DIAGNOSTICE TESTING FACILITY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. EDMOND S MAXON LBSW (ED)
(817) 494-6875
Entity
Organization
Contact information
Practice address
1661 WOODARD AVE, SUITE 110, CLEBURNE, TX 76033-7052
(817) 494-6875
Mailing address
1661 WOODARD AVE, SUITE 110, CLEBURNE, TX 76033-7052
(817) 494-6875
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
22799
TX
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
22799
TX
Other
Enumeration date
10/12/2011
Last updated
10/12/2011
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