MEDICARE: JACKSON DIAGNOSTIC IMAGING, 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	261QR0208X	Mobile Radiology Clinic/Center

General Provider Information

NPI Number	:	1750513016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON DIAGNOSTIC IMAGING, INC

Provider Business Mailing Address
First Line	:	65 3RD ST NW
Second Line	:	SUITE 200
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4670
Country	:	US
Telephone Number	:	863-299-2424
Fax Number	:	863-299-4848

Provider Business Practice Location Address
First Line	:	65 3RD ST NW
Second Line	:	SUITE 200
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4670
Country	:	US
Telephone Number	:	863-299-2424
Fax Number	:	863-299-4848

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MS. SARELYN BERTINA JACKSON
Credential	:
Telephone Number	:	863-299-2424

Provider Enumeration Date	:	08/19/2009
Last Update Date	:	11/05/2010

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