1205888468 NPI number — SUMMERLIN IMAGING CENTER LLC

Table of content: (NPI 1205888468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205888468 NPI number — SUMMERLIN IMAGING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMERLIN IMAGING CENTER 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:
SUMMERLIN 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:
1205888468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6415 LAKE WORTH RD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33463-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-331-0808
Provider Business Mailing Address Fax Number:
561-237-6034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 BARKLEY CIR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-4545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-425-0370
Provider Business Practice Location Address Fax Number:
239-425-0380
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERS
Authorized Official First Name:
BRADFORD
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
561-331-0808

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  HCC4472 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V2882 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 105547400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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