Basic Information
Provider Information | |||||||||
NPI: | 1124287990 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | A1 IMAGING OF JACKSONVILLE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HORIZON JACKSONVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 BAYVIEW CIR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | NEWPORT BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 926602983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493364336 | ||||||||
FaxNumber: | 9493364346 | ||||||||
Practice Location | |||||||||
Address1: | 6349 BEACH BLVD | ||||||||
Address2: | SUITE 1A | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322162707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9047223939 | ||||||||
FaxNumber: | 9047223922 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2008 | ||||||||
LastUpdateDate: | 06/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BABITZ | ||||||||
AuthorizedOfficialFirstName: | ALAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9493364336 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | A1 IMAGING CENTERS LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
No ID Information.