Basic Information
| Provider Information | |||||||||
| NPI: | 1013908912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDEPENDENT IMAGING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1313 | ||||||||
| Address2: | |||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334701313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5613187163 | ||||||||
| Practice Location | |||||||||
| Address1: | 3347 STATE ROAD 7 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334498095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617955558 | ||||||||
| FaxNumber: | 5617927300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | ARTHUR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5617661300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | HCC1449 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | HCC8429 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | V000B | 01 | FL | BCBS | OTHER | 003527600 | 05 | FL | MEDICAID |