Healthcare Provider Details

I. General information

NPI: 1376675538
Provider Name (Legal Business Name): SHORES DIAGNOSTIC CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8855 NE 2ND AVE
EL PORTAL FL
33138
US

IV. Provider business mailing address

PO BOX 530506
MIAMI SHORES FL
33153-0506
US

V. Phone/Fax

Practice location:
  • Phone: 305-759-0074
  • Fax: 305-754-4766
Mailing address:
  • Phone: 305-759-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MIRNELLE JOSMA
Title or Position: PRESIDENT
Credential: AS RTM
Phone: 305-759-0074