1710258504 NPI number — MP DIAGNOSTIC LTD

Table of content: (NPI 1710258504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710258504 NPI number — MP DIAGNOSTIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MP DIAGNOSTIC LTD
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:
1710258504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33116-0608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-242-8900
Provider Business Mailing Address Fax Number:
786-923-2199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6401 SW 87 AVENUE
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33173-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-273-9290
Provider Business Practice Location Address Fax Number:
786-923-2199
Provider Enumeration Date:
01/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
POZO
Authorized Official First Name:
GRACIELA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT OF CORP GEN PART
Authorized Official Telephone Number:
305-271-8394

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  HCC9844 , 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: 004623400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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