Healthcare Provider Details

I. General information

NPI: 1922396779
Provider Name (Legal Business Name): PROFESSIONAL DIAGNOSTIC READING MRI INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3728 PHILLIPS HWY STE34
JACKSONVILLE FL
32207-9300
US

IV. Provider business mailing address

3728 PHILLIPS HWY STE34
JACKSONVILLE FL
32207-9300
US

V. Phone/Fax

Practice location:
  • Phone: 904-399-2500
  • Fax: 904-399-2495
Mailing address:
  • Phone: 904-399-2500
  • Fax: 904-399-2495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number1000032322
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number1000032322
License Number StateFL

VIII. Authorized Official

Name: JOSE VIVAS
Title or Position: CFO
Credential:
Phone: 904-399-2500