Healthcare Provider Details

I. General information

NPI: 1972071108
Provider Name (Legal Business Name): VITAL IMAGING DIAGNOSTIC CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 PALM AVE UNIT 1
HIALEAH FL
33012-5212
US

IV. Provider business mailing address

7101 SW 99TH AVE
MIAMI FL
33173-4661
US

V. Phone/Fax

Practice location:
  • Phone: 305-596-9992
  • Fax:
Mailing address:
  • Phone: 305-596-9992
  • 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: JUAN PUIG
Title or Position: MGRM
Credential:
Phone: 305-596-9992