Healthcare Provider Details

I. General information

NPI: 1689807976
Provider Name (Legal Business Name): IMPERIAL GROUP SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 NW 72ND AVE SUITE 3157-A
MIAMI FL
33126-3009
US

IV. Provider business mailing address

777 NW 72ND AVE SUITE 3157-A
MIAMI FL
33126-3009
US

V. Phone/Fax

Practice location:
  • Phone: 786-768-4882
  • Fax:
Mailing address:
  • Phone: 786-768-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: VICTOR RAMON CASTILLO
Title or Position: PRESIDENT
Credential:
Phone: 786-768-4882