Healthcare Provider Details

I. General information

NPI: 1689706863
Provider Name (Legal Business Name): PEMBROKE WEST DIAGNOSTIC IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 SHERIDAN ST SUITE 101
HOLLYWOOD FL
33026-1505
US

IV. Provider business mailing address

11011 SHERIDAN ST SUITE 101
HOLLYWOOD FL
33026-1505
US

V. Phone/Fax

Practice location:
  • Phone: 954-443-8010
  • Fax: 305-412-8265
Mailing address:
  • Phone: 954-443-8010
  • Fax: 305-412-8265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN E CIANCIULLI
Title or Position: PRESIDENT
Credential:
Phone: 305-275-6069