Healthcare Provider Details

I. General information

NPI: 1114247053
Provider Name (Legal Business Name): CLEVELAND RADIOLOGY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12995 S CLEVELAND AVE STE 182
FORT MYERS FL
33907-7719
US

IV. Provider business mailing address

12995 S CLEVELAND AVE STE 182
FORT MYERS FL
33907-7719
US

V. Phone/Fax

Practice location:
  • Phone: 305-775-9986
  • Fax:
Mailing address:
  • Phone: 305-775-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MARIO FONSECA
Title or Position: GENERAL MANAGER
Credential:
Phone: 305-775-9986