Provider Demographics
NPI:1578214284
Name:MEDIVEST DENTON, LP
Entity type:Organization
Organization Name:MEDIVEST DENTON, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:MECHELLE
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-377-3800
Mailing Address - Street 1:3712 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2536
Mailing Address - Country:US
Mailing Address - Phone:817-202-5179
Mailing Address - Fax:817-377-3801
Practice Address - Street 1:1713 S FM 51 # 104
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3642
Practice Address - Country:US
Practice Address - Phone:817-377-3800
Practice Address - Fax:817-377-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-13
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No293D00000XLaboratoriesPhysiological Laboratory