Healthcare Provider Details

I. General information

NPI: 1215008941
Provider Name (Legal Business Name): WEST FLORIDA PET SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 VONDERBURG DR SUITE 3009
BRANDON FL
33511-5980
US

IV. Provider business mailing address

510 VONDERBURG DR SUITE 3009
BRANDON FL
33511-5980
US

V. Phone/Fax

Practice location:
  • Phone: 813-657-4914
  • Fax: 813-657-4916
Mailing address:
  • Phone: 813-657-4914
  • Fax: 813-657-4916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0207X
TaxonomyMobile Mammography Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LAVELLE R HARDIN
Title or Position: ANALYST
Credential:
Phone: 615-344-8203