1235406646 NPI number — MANATEE DIAGNOSTIC CENTER,LTD

Table of content: (NPI 1235406646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235406646 NPI number — MANATEE DIAGNOSTIC CENTER,LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANATEE DIAGNOSTIC CENTER,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:
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:
1235406646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 60TH STREET COURT WEST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-747-3034
Provider Business Mailing Address Fax Number:
941-748-5819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 60TH STREET COURT WEST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-747-3034
Provider Business Practice Location Address Fax Number:
941-748-5819
Provider Enumeration Date:
11/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W
Authorized Official Title or Position:
EXECTIVE DIRECTOR/CFO
Authorized Official Telephone Number:
941-747-3034

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  ME6540 , 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: 48245500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com