1316596471 NPI number — SUMMERLIN IMAGING CENTER LLC

Table of content: MS. ELEANOR BURKE WILKINSON D.P.T. (NPI 1679661193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316596471 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:
Provider Other Organization Name Type Code:
6
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:
1316596471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2020
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:
3550 UNIVERSITY BLVD S STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-4227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-331-0808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2019

Additional Information

Authorized Official

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

Provider Taxonomy Codes

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

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

  • Identifier: 108829500 . 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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