Basic Information
| Provider Information | |||||||||
| NPI: | 1083283055 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678454 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004756112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5440 S WILLIAMSON BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862747118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | FALCO | ||||||||
| AuthorizedOfficialFirstName: | AL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3862747118 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST CENTRAL FLORIDA OUTPATIENT IMAGING LLC | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.