Basic Information
| Provider Information | |||||||||
| NPI: | 1275664336 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA CLUB DIAGNOSTIC CENTER, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 IVES DAIRY RD | ||||||||
| Address2: | SUITE # 14 | ||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331792450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054050365 | ||||||||
| FaxNumber: | 3054050370 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 IVES DAIRY RD | ||||||||
| Address2: | SUITE # 14 | ||||||||
| City: | NORTH MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331792450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054050365 | ||||||||
| FaxNumber: | 3054050370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BARANOV | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3054050365 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.