Healthcare Provider Details

I. General information

NPI: 1992260566
Provider Name (Legal Business Name): PRECIOUS MOMENTS 3D - 4D LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5336 US HIGHWAY 98 N
LAKELAND FL
33809-0517
US

IV. Provider business mailing address

5336 US HIGHWAY 98 N
LAKELAND FL
33809-0517
US

V. Phone/Fax

Practice location:
  • Phone: 863-816-3870
  • Fax: 863-434-7586
Mailing address:
  • Phone: 863-816-3870
  • Fax: 863-434-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. PAMELA MARIA GUTIERREZ
Title or Position: OWNER
Credential: RDMS
Phone: 863-529-7448