MEDICARE: IDEAL IMAGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency	9294421	FL

General Provider Information

NPI Number	:	1073978607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL IMAGE

Provider Business Mailing Address
First Line	:	17504 PRESERVE WALK LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3243
Country	:	US
Telephone Number	:	813-549-2299
Fax Number	:

Provider Business Practice Location Address
First Line	:	17504 PRESERVE WALK LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3243
Country	:	US
Telephone Number	:	813-549-2299
Fax Number	:

Authorized Official
Title or Position	:	ARNP
Name	:	SHELLY ATALIG
Credential	:
Telephone Number	:	813-748-1527

Provider Enumeration Date	:	12/26/2015
Last Update Date	:	12/26/2015

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Directions to “IDEAL IMAGE ” Practice Location

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