Healthcare Provider Details

I. General information

NPI: 1811994551
Provider Name (Legal Business Name): ULTRA IMAGING OF TAMPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 LAKELAND HIGHLANDS RD HIGHLANDS PLAZA
LAKELAND FL
33803-4379
US

IV. Provider business mailing address

2946 LAKELAND HIGHLANDS RD HIGHLANDS PLAZA
LAKELAND FL
33803-4379
US

V. Phone/Fax

Practice location:
  • Phone: 863-583-1674
  • Fax: 863-583-1678
Mailing address:
  • Phone: 863-583-1674
  • Fax: 863-583-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) 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. LAVELLE R HARDIN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 615-344-8203