Healthcare Provider Details

I. General information

NPI: 1235239120
Provider Name (Legal Business Name): GOLDCOAST ULTRASOUND INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17979 86TH STREET NORTH
LOXAHATCHEE FL
33470
US

IV. Provider business mailing address

17979 86TH STREET NORTH
LOXAHATCHEE FL
33470
US

V. Phone/Fax

Practice location:
  • Phone: 954-389-4210
  • Fax: 561-422-3377
Mailing address:
  • Phone: 954-389-4210
  • Fax: 561-422-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number StateFL

VIII. Authorized Official

Name: MAYLI HERNANDEZ
Title or Position: PRESIDENT
Credential:
Phone: 954-389-4210