1588623904 NPI number — BROWARD PET IMAGING CENTER LLC

Table of content: (NPI 1588623904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588623904 NPI number — BROWARD PET IMAGING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROWARD PET 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:
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:
1588623904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4850 WEST OAKLAND PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
LAUDERDALE LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-735-6330
Provider Business Mailing Address Fax Number:
975-739-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4850 WEST OAKLAND PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
LAUDERDALE LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-735-6330
Provider Business Practice Location Address Fax Number:
975-739-1924
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAUER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
954-739-0978

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: 264327800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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