1124038732 NPI number — SPORTS IMAGING CENTERS, LLC

Table of content: (NPI 1124038732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124038732 NPI number — SPORTS IMAGING CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS IMAGING CENTERS, 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:
1124038732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 VIRGINIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-466-5050
Provider Business Mailing Address Fax Number:
772-467-1003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 VIRGINIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-466-5050
Provider Business Practice Location Address Fax Number:
772-467-1003
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUKE
Authorized Official First Name:
DEBY
Authorized Official Middle Name:
YYONNE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
772-466-5050

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  HCC8031 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 001110400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: V1780 . This is a "BC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V1780 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 001110400 . 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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