1659365021 NPI number — ADVANCED IMAGING OF PORT CHARLOTTE LLC

Table of content: (NPI 1659365021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659365021 NPI number — ADVANCED IMAGING OF PORT CHARLOTTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED IMAGING OF PORT CHARLOTTE 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:
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:
1659365021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2625 TAMIAMI TRL
Provider Second Line Business Mailing Address:
UNIT 1
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-6478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-235-4646
Provider Business Mailing Address Fax Number:
941-235-4655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2625 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
UNIT 1
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-6478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-235-4646
Provider Business Practice Location Address Fax Number:
941-235-4655
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FABIAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-235-4646

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , 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: DC8795 . This is a "GROUP RAILROAD NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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