1053885962 NPI number — INNOVATIVE IMAGING ASSOCIATES, PLLC

Table of content: (NPI 1053885962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053885962 NPI number — INNOVATIVE IMAGING ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE IMAGING ASSOCIATES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053885962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 W. AZEELE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-481-0595
Provider Business Mailing Address Fax Number:
813-336-6962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11375 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-476-6295
Provider Business Practice Location Address Fax Number:
813-336-6962
Provider Enumeration Date:
01/14/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HUANG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
646-265-5388

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)