1093757486 NPI number — EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC

Table of content: (NPI 1093757486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093757486 NPI number — EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC
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:
PORT ORANGE IMAGING CENTER
Provider Other Organization Name Type Code:
3
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:
1093757486
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1673 MASON AVE
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32117-5515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-274-7118
Provider Business Mailing Address Fax Number:
386-274-6173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1195 DUNLAWTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-4745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-763-5300
Provider Business Practice Location Address Fax Number:
386-322-1616
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FALCO
Authorized Official First Name:
AL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
386-274-7118

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0203X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: V2885 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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