MEDICARE: SANTA CLARA DIAGNOSTIC CENTER INC

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	261QR0200X	Radiology Clinic/Center		FL

General Provider Information

NPI Number	:	1215921820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA CLARA DIAGNOSTIC CENTER INC

Provider Business Mailing Address
First Line	:	1275 W 47TH PL
Second Line	:	416
City	:	HIALEAH
State	:	FL
Zip	:	33012-3394
Country	:	US
Telephone Number	:	305-828-1749
Fax Number	:	305-828-1022

Provider Business Practice Location Address
First Line	:	1275 W 47TH PL
Second Line	:	416
City	:	HIALEAH
State	:	FL
Zip	:	33012-3394
Country	:	US
Telephone Number	:	305-828-1749
Fax Number	:	305-828-1022

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LARRY RUIZ
Credential	:
Telephone Number	:	305-498-5658

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	09/26/2011

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