1407957434 NPI number — AMBULATORY DIAGNOSTIC CENTER INC

Table of content: (NPI 1407957434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407957434 NPI number — AMBULATORY DIAGNOSTIC CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBULATORY DIAGNOSTIC CENTER INC
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:
PONCE DE LEON DIAGNOSTIC SERVICES LTD
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:
1407957434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
747 PONCE DE LEON BLVD
Provider Second Line Business Mailing Address:
FIRST FLOOR
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33134-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-446-7893
Provider Business Mailing Address Fax Number:
305-442-1183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
747 PONCE DE LEON BLVD
Provider Second Line Business Practice Location Address:
FIRST FLOOR
Provider Business Practice Location Address City Name:
CORAL GABLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33134-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-446-7893
Provider Business Practice Location Address Fax Number:
305-442-1183
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRACERAS
Authorized Official First Name:
WILFRED
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-863-8860

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 058543200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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