1295862605 NPI number — HENDRY DIAGNOSTIC IMAGING CENTER

Table of content: (NPI 1295862605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295862605 NPI number — HENDRY DIAGNOSTIC IMAGING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENDRY DIAGNOSTIC IMAGING CENTER
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:
1295862605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 151908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33915-1908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-242-5237
Provider Business Mailing Address Fax Number:
239-242-7274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 W SAGAMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEWISTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33440-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-983-1103
Provider Business Practice Location Address Fax Number:
863-983-0307
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BASILE
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
C
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
863-983-1103

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 27010A . This is a "BCBS# MEDICAL DIRECTOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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